Professional Documents
Culture Documents
DEDICATION
Professor Donald Hillman died on 4th July 2006. He was a world renowned
paediatrician, a champion of International Health, and a strong advocate for
improving child health worldwide, particularly in developing countries. This third
edition of “The Primary Health Care manual for medical students and other health
workers” is dedicated to Don Hillman. His work will forever live on through the
generations of undergraduate and postgraduate medical students all over the world
whom he mentored and influenced in their careers, together with his wife Liz Hillman.
From 1976 to 1989 Don Hillman and his wife Liz Hillman joined the then new Faculty
of Medicine at Memorial University of Newfoundland as Professors of Paediatrics.
Don Hillman became Physician-in-Chief and Liz Hillman was Director of Ambulatory
Education at the Janeway Child Health Centre. In 1989 The Hillmans joined
McMaster University in Hamilton in the field of international health. They later moved
on to the University of Ottawa in the same field, now generally referred to as Global
Health.
Internationally the Hillmans have also had a long and illustrious career having
worked in more than 15 countries as consultants or visiting Professors. This includes
Kenya, Uganda, Tanzania, Zambia, South Africa, China, Kuwait, Singapore, Laos,
Malaysia, Bhutan, India, Guyana, Philippines and Pakistan. In the early 1970s McGill
University teamed up with the Canadian International Developing Agencies (CIDA) to
support the development of a new medical school at the University of Nairobi in
Kenya. In 1974 Don and Liz Hillman accepted a four year appointment in the
Department of Paediatrics and Child Health at the University of Nairobi. They worked
together with Prof. Nimrod Bwibo and Dr. Alan Ross to strengthen the teaching of
Paediatrics and Child Health at the University of Nairobi. This has now grown to be
one of the largest undergraduate and postgraduate medical teaching programmes in
Africa. Don and Liz Hillman later moved on to Makerere University in Uganda where
they managed another CIDA funded project known as CHAMP (the Child Health and
Maternal Educational Programme). They also served in senior advisory positions
with UNICEF Kampala
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The McGill and Nairobi programmes and the CHAMP programme in Uganda were
later to influence the development of the CIDA funded Primary Health Care East
Africa (PHCEA) project in the late 1980s which was negotiated and championed by
the Hillmans. The PHCEA project focused on improving the teaching of Paediatrics
and Child Health in Kenya, Uganda, Tanzania and Zambia, including the exchange
of students and staff. This project produced a popular teaching manual - The Primary
Health Care manual for medical students and other health workers - which is still in
use today in at least five medical schools and is stocked in several libraries.
The Hillmans have also supported the development of new medical schools at Moi
University (in Eldoret, Kenya), at Mbarara University for Science and Technology
(Uganda), and at Gulu University (Uganda). Following their retirement in Canada,
they continued their active involvement abroad in international health by serving as
consultants or visiting professors. They undertook and completed assignments for
Canadian External Services Organization (CESO) in Kenya, India, Guyana,
Philippines and Pakistan. At the time of Don's death, the Hillmans were working on a
project funded by the Royal College of Physicians and Surgeons of Canada in
Zambia, Tanzania, Kenya and Uganda.
As we celebrate the life of Don Hillman, we thank him and his wife Liz for the
tremendous contribution and lifetime commitment to international health, which will
remain an inspiration for many years to come, to all of us including many generations
of medical students and paediatricians all over the world. We dedicate this third
edition of the “Primary Health Care Manual for medical students and other health
workers” to our friend Don Hillman.
Formerly:
Chairman of the Department of Paediatrics and Child Health at the University of
Zambia
Dean School of Medicine, University of Zambia (1984-1992)
Senior Health Adviser in UNICEF (1992-2009)
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Don Hillman, together with his wife Liz mooted the whole idea of the PHC East Africa
Project and the subsequent publication of the PHC manual. We have written an
obituary printed in this book to honour the life and work of Prof. Donald Hillman.
The PHC manual is still very frequently used to teach both undergraduate and
postgraduate medical students. This new edition will be distributed free of charge to
seven medical schools in five countries in Eastern and Southern Africa. These are
Zambia, Kenya, Tanzania, Uganda, and Ethiopia. The first two editions of the manual
proved to be extremely popular among medical students and other health workers.
The major preparation of the third edition of the PHC manual took place at a meeting
held at the Silver Springs Hotel in Nairobi in October 2008. It was a wonderful and
productive meeting with representatives of 10 Universities present, including one
representative from UNICEF. Other topics covered during the meeting included;
sharing information on the postgraduate curriculum, exchange of staff and students,
and conduction of joint research.
With five years remaining towards the attainment of the MDGs by 2015, the PHC
manual will make an important contribution in assisting countries to achieve the
health related MDGs. A few new chapters have been added to the manual to make it
more comprehensive. We have also included the April 2008 Ouagadougou
Declaration on PHC in Africa, which was signed by Ministers of Health from all
countries in Africa.
May the spirit of Don Hillman continue to guide the future direction of the PHC
manual and its use by medical students and other health workers!
Finally let me once again thank all my colleagues who participated in the production
of this third edition. Their commitment was total as they showed an incredible
patience and understanding in waiting for the final production of the new manual. I
also wish to thank Ms. Ruth Matano and Ms. Rosemary Mwasya for assisting us in
organizing an extremely successful workshop to revise the third edition of the
manual. Ms. Matano also assisted in preparing the final script of the new manual.
Kopano Mukelabai, 31st March 2010.
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To Prof. Gabriel Anabwani, the first programme manager of PHC/EA project, who
worked so hard to overcome most of the teething problems encountered, I say
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special thanks, and thanks go to all our departmental Secretaries who bore the brunt
of retyping the illegible manuscripts. Particular thanks go to Mrs. Jane Thairu,
University of Nairobi for typing the draft manuscript on her ACER 910, and to Mrs.
Beatrice Mwanamuchende and Ms. Shirley Kapapa of University of Zambia who
typed the revised final manuscripts.
Finally my gratitude goes to all our students and fellows whose constant quest for
more knowledge was the prime mover for the production of this manual.
The following are thanked for contributing directly or indirectly to the manual:
Prof. Donald Hillman, Memorial University, Newfoundland;
Prof. Elizabeth Hillman, Memorial University, Newfoundland;
Prof. Stuart Macleod, Dean, MacMaster University, Hamilton, Canada;
Prof. Vic Neufeld, McMaster University, Canada;
Prof. N. Bwibo, former Principal, University of Nairobi, College of Health Sciences;
Prof. H. Pamba. former Dean, Faculty of Medicine, University of Nairobi;
Prof. W. Makene - former Dean, Muhimbili Medical Center Dar-es-Salaam;
Prof. G. Mwaluko, former Dean and Director General, Muhimbili Medical Centre,
Dar-es-Salaam;
Prof. J. W. Mugerwa, Dean Faculty of Medicine, Makerere University;
Prof. R. Owor - Former Dean, Faculty of Medicine, Makerere University;
Prof. Julius Meme, former Chairman, Dept. of Paediatrics and Child Health,
University of Nairobi;
Prof, F. Onyango, Chairman, Dept. of Paediatrics and Child Health, University of
Nairobi;
Prof. R. Mbise, former Chairman, Dept. of Paediatrics and Child Health, University of
Dar-es-Salaam;
Dr. E. Mwaikambo, Chairman, Dept. of Paediatrics and Child Health, Muhimbili
Medical Center, Dar-es-Salaam;
Prof. C. Ndugwa, Chairman, Dept. of Paediatrics and Child Health, Makerere
University, Kampala;
Prof. K. Mukelabai, Dean and former Chairman of Department of Paediatrics and
Child Health, University of Zambia, Lusaka;
Dr. Alfred Mutema, Nairobi;
Mr. L. Dierick, Nairobi;
Prof. Peter Kinyanjui, Common Wealth of Learning, University of Vancouver Canada;
UNICEF; All Primary Health Care East Africa Fellows; All Faculty members of
departments of Paediatrics and Child Health at Universities of Zambia ; Dar-es-
Salaam, Makerere and Nairobi. Finally I wish to thank all my colleagues for their
maximum cooperation and patience in implementing the PHC/EA project to the end.
This manual lends credit to your dedicated and excellent efforts.
Prof. Kopano Mukelabai, Dean School of Medicine, University of Zambia, Former
Chairman of the Department of Paediatrics. University of Zambia.
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A MESSAGE FROM DR. HAFDAN MAHLER, FORMER DIRECTOR GENERAL OF THE
WORLD HEALTH ORGANIZATION
In many cases, so far, the answer is no. We can go on and on developing plans: nothing
will happen unless all health workers, all health managers, and key professionals in other
sectors come to realize what is at stake.
First, health workers must understand that the concept of primary health care involves new
roles for them and a new outlook. Not only should we be concerned with disease
prevention and control, we must also be concerned with health promotion and care - and
not least with development in general – and with people. Our health technologies must be
based on what the people themselves want and need. In other words, the worker should
learn first and foremost to act as a facilitator of action by individuals, families and
communities. We must stop trying to fit communities into systems and programs we
devise, without a real and deep feeling for the social aspects of health problems or the
economic constraints-not to speak of the cultural dissonance that is often the backlash of
such programs.
Second, health workers must accept their new roles. They must accept new ideas, must
be taken to try them out, to adapt them, to broaden their scope and innovate in the
partnership approach. Their main concept must be to find ways of helping individuals and
communities become self-reliant. It must be made clear that advocating self-reliance in
health matters in no way means abdicating our responsibilities and passing them on to
someone else. Both lay persons and professionals are essential. They cannot replace
each other, but they must work together.
This brings me to my third point: health workers must have the necessary skills to perform
these new roles effectively and to make efficient use of existing knowledge. This calls for a
training force fully familiar with accumulated experience and keen to provide the kind and
quality of professional preparation needed. It also calls for full backing from health
managers for such training.
All health care workers must meet these requirements. This manual helps define the role
of health workers in Primary Health Care. Your skills and commitment to this role will be of
critical importance to the achievement of Health for All by the year 2000.
TABLE OF CONTENTS
Page No.
43 4 CHILD NUTRITION
Ruth Nduati, Ahmed Laving, Heena Hooker,
Peter Ngwatu
97 7 CHILDHOOD IMMUNIZATION
Amos Odiit, Esther D. Mwaikambo
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Page No. CHAPTERS AND AUTHORS
Elizabeth Maleche-Obimbo,
Dalton Wamalwa, Gabriel Anabwani
“A world that is greatly out of balance in matters of health is neither stable nor secure.
Viewed against current trends, primary health care looks more and more like a smart
way to get health development back on track. Thirty years of well-monitored experience
tell us what works and where we need to head, in rich and poor countries alike.”
Introduction
Like many great and timely ideas, Primary Health Care emerged in several places at the
same time. In China, the success of the barefoot doctors, local village health workers
trained in first aid with a focus on prevention, improved health for rural Chinese on a
grand scale. In South East Asia, the importance of prevention, local midwives,
community involvement and good nutrition was documented in Health in the Developing
World by John Bryant
Africa too was moving towards a focus on more accessible care. In Uganda in the
1960s, Maurice King, a microbiologist teaching at Makerere undertook a locum for a
friend in the Karamoja, a remote region of nomadic people with few health care workers.
It was an eye-opener and led to his collecting a group of like–minded physicians in
Africa for a symposium. From this meeting, a classic text on primary health care,
Medical Care in the Developing World, subtitled a Primer on the Medicine of Poverty
was published. For the first time the relationship between the catchment area of a
health facility and the time it takes to walk to and fro appeared in print. Not
unexpectedly almost 90 per cent of those seeking care from a health unit were drawn
from a radius of less than 5 km – the distance a mother with a child on her back, or a
toddler in tow, could walk in a day. This finding led to a reassessment of the role of
hospitals and the need for more accessible care.
A pediatrician working in West Africa, David Morley introduced the concept of Under- 5
Clinics dealing with mothers and children, who are the most vulnerable members of the
community. In another classic, Pediatrics Priorities in the Developing World, he
pioneered an improved design of such clinics to allow more and better care for children
and their mothers. About the same time, important aspects of nutrition, such as the
onset of kwashiorkor in the older child weaned early when a new child is born, were
identified by the Jelliffes and Cecily Williams.
This set the scene for the WHO, UNICEF and the NGOs to pull together the WHO
Declaration of Primary Health Care in Alma Ata in 1978 with the goal of Health for All by
the Year 2000. At the time there was concern that such a lofty goal was unattainable.
But health workers in the developing world were insistent that the goal was needed and
could be achieved.
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Objectives:
Learning Activities:
Read the Declaration of Alma Ata, WHO, 1978 Report of the International Conference
of PHC; Chapter 1, UNICEF State of the World, 2008 and World Health Report 2008 on
PHC and Ouagadougou Declaration on PHC and Health Systems in Africa, 2008
Meet with district and local health staff, UNICEF and NGOs to become familiar with
existing PHC programs and available reference materials.
Health is defined as a state of complete physical, mental, social and spiritual well
being and not merely the absence of disease or infirmity. These four elements of
well being influence each other. When the influence is positive the individual enjoys
a healthy life. Conversely when the influence is negative the individual suffers ill
health. WHO
Outline a PHC approach to a specific child health issue.
Definition of PHC:
PHC is spelled out in detail in Article VI of the Declaration of Alma Ata.
“Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and the country can afford to maintain at every stage of their development in
the spirit of self-reliance and self-determination. It forms an integral part both of the
country’s health system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the first level of
contact of individuals, the family and community with the national health system bringing
health care as close as possible to where people live and work and constitutes the first
element of a continuing health care process.”
Alma Ata, 1978
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The 8 Elements of PHC
The eight elements or program of PHC spell out MEDICINE and are sometimes referred
to as the New Medicine
For almost all children, the most important primary health care
worker is the mother.
E - Education
Health education needs to be interactive, pervasive and eagerly taken up by all
health workers. Female literacy is one of the most important ways to improve a
family’s health. Globally four out of ten women are illiterate and in some countries
as many as eight out of ten. Educating girls is closely associated with falling infant
mortality, decreasing birth rates and improved nutrition.
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C – Control of Endemic Disease
Endemic diseases are those commonly found in a region. Malaria is endemic in Sub-
Saharan Africa and meningitis is endemic in the meningitis belt of Northern Africa.
Appropriate technology has been identified to assist with control of many endemic
diseases including insecticide-treated bed nets in malarial areas and ORS for
treatment of diarrhea.
I – Treatment of Illness and Injury
Curative care for illness or injury is but one of the eight PHC programs. Care needs to
be provided close to where people live. Appropriate, accessible treatment also needs to
be affordable. In many developing countries poor people now pay two- ten times more
out of the own pocket for their health care than is provided by the government.
Acceptable
E – Essential Drugs Affordable
Essential drugs are the basic drugs needed to treat Accessible
common illnesses and disease in a country. PED Appropriate
DRUGS NEEDED Most developing countries have 20
drugs for rural dispensaries and health centers and a
somewhat larger but still limited list of drugs for
hospitals. A system to ensure ongoing supply, storage, dispensing and training of
staff is a key part of ensuring provision of essential drugs.
Some countries included other programs into the basic health program list such as
dental care and mental health but all countries had the basic eight PHC elements.
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Characteristics of PHC
Community Participation
Participation is more than involvement and
is much more than contributing labour and
Support Breastfeeding time although both are often necessary.
Participation means being included in
Allow mothers to have their babies with planning, decision-making, implementation
them and evaluation. Through full participation
Let mothers put their babies to the breast people grow in knowledge and confidence
soon after birth and can be empowered to make the
Help mothers overcome problems changes needed to improve their health and
Provide correct information to mothers that of their families. Participation needs to
Eliminate routine bottle-feeding involve women and the disadvantaged.
Eliminate free samples of breastmilk
substitutes Intersectoral Collaboration
Remove all advertising for breast milk Health is much more than merely the
substitutes absence of disease. Health involves the
food we eat, the work we do, the
relationship we have and the education we
receive. To fully achieve health we need to
work collaboratively with those in other
sectors such as education, agriculture,
women’s affairs, local government etc. For
example, what is taught in school can be
improved to ensure children are taught
about important health problems, such as
diarrhoea and how it can be managed using
ORS.
Prevention
Since there will never be sufficient resources to treat all current
and possible diseases, we need to begin to prevent those that
can be prevented. Prevention is not only better for people, it
also saves money. Most people, given the information and
opportunity are more interested in preventing health problems
than dealing with disease.
Appropriate Technology
Appropriate technology is technology which the community
can afford, implement and maintain. It needs to be simple,
effective and scientifically sound so it will be sustainable.
The Tippy Tap used
Simple solutions have been provided which prevent many
for washing hands,
illnesses. Examples include: Oral rehydration salts; Child to
delivers small
Child programs in First Aid;
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Training of Traditional Birth Attendants (TBA) in prenatal care; Tippy Taps and energy
efficient stoves.
Decentralization
Decentralization of health care puts control back into the hands of the local community.
Decentralization devolves responsibility for health to district health teams and provides
them with the training and the resources to do it.
Sustainability
Sustainability is the ability to carry on and maintain services. Attention to sustainability
is needed at the time programs are first put in place, so that once established, they can
be continued. Hopefully many health programs can be sustained by the community with
minimal outside assistance.
“There isn’t a single problem in global health that we don’t have the means to deal with.
It is not even that expensive. It just requires commitment, expertise and resources.”
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PHC Responding to a Changing World
Ongoing Challenges
High maternal, infant, and under-five mortality often indicates lack of access to basic
services such as clean water and sanitation, immunizations and proper nutrition. Vast
differences in health occur within countries and sometimes within individual cities. In
Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the high-
income area. In a slum in the same city, the rate is 254 per 1000.
Of the estimated 136 million women who will give birth this year, around 58 million will
receive no medical assistance whatsoever during childbirth and the postpartum period,
endangering their lives and that of their infants.
After thirty years of PHC activity, WHO suggested that many health systems have lost
their focus on fair access to care, their ability to invest resources wisely, and their
capacity to meet the needs and expectations of people, especially in impoverished and
marginalized groups. As well, inequitable access, impoverishing costs, and erosion of
trust in health care constitute a threat to social stability.
When countries at the same level of economic development are compared, those
where health care is organized around the tenets of primary health care produce a
higher level of heath for the same investment. Such lessons take on critical importance
at a time of global financial crisis.
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“It is in child health that the greatest of all gains can now be made. Today, a solid
scientific consensus stands behind a body of knowledge, traditional as well as modern,
discovered or rediscovered, which can enable most families to prevent as well as treat
almost all the major causes of child death and malnutrition at a cost which they can
afford.”
In calling for a return to primary health care, WHO and UNICEF argue that its values,
principles and approaches are more relevant now and inequalities in health outcomes
and access to care are much greater today than they ever were before.
In far too many cases, people who are well-off and generally healthier have the best
access to the best care, while the poor are left to fend for themselves. Health care is
often delivered according to a model that concentrates on disease, high technology, and
specialist care, with health viewed as a product of biomedical interventions and the
power of prevention largely ignored.
Specialists may perform tasks that are better managed by other health workers. This
contributes to inefficiency, restricts access, and deprives patients of opportunities for
comprehensive care. When health is skewered towards specialist care, a broad menu of
protective and preventive interventions tends to be lost.
WHO estimates that better use of existing preventive measures could reduce
the global burden of disease by as much as 70%.
Inequities in access to care and in health outcomes are usually greatest in cases where
health is treated as a commodity and care is driven by profitability. The results are
predictable: unnecessary tests and procedures, more frequent and longer hospital
stays, higher overall costs, and exclusion of people who cannot pay.
In the developing world, care tends to be fragmented into discrete initiatives focused on
individual diseases or projects, with little attention to coherence and little investment in
basic infrastructures, services, and staff. Above all, health care is failing to respond to
rising social expectations for health care that is people-centred, fair, affordable and
efficient.
A primary health care approach, when properly implemented, protects against many of
these problems. It promotes a holistic approach to health that makes prevention equally
important as cure in a continuum of care that extends throughout the lifespan. As part of
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this holistic approach, it works to influence fundamental determinants of health that
arise in multiple non-health sectors, offering an upstream attack on threats to health.
Primary health care brings balance back to health care, and puts families and
communities at the hub of the health system. With an emphasis on local ownership, it
honours the resilience and ingenuity of the human spirit and makes space for solutions
created by communities, owned by them, and sustained by them.
The core strategy for tackling inequalities is to move towards universal coverage in a
spirit of equity, social justice, and solidarity. Fairness, efficiency and compassion in
service delivery especially targeting the most vulnerable populations, should be the
overarching goals.
Primary health care also offers the best way of coping with the ills of life in the 21st
century: the globalization of unhealthy lifestyles, rapid unplanned urbanization,
environmental changes and the ageing of populations. These trends contribute to a rise
in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, which
create new demands for long-term care and strong community support. A multisectoral
approach is central to prevention, as the main risk factors for these diseases lie outside
the health sector.
REFERENCES:
UNICEF, State of the World’s Children, 2008.
Alma Ata Declaration, Report of the International Conference on Primary Health Care,
06-12 September 1978, WHO Bulletin, Geneva 1978
World Health Report 2008, PHC
Ouagadougou Declaration on PHC and Health Systems in Africa, April 2008
“Too many of us still think of medical care systems or interventions rather than thinking
along new lines in order to understand the determinants of the new problems and to
grasp opportunities that reach beyond the health care system….we do not need just a
little bit more health education here and there; we need a new approach to action and a
strong alliance to move us forward.’
Halfdan Mahler
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Upstream Downstream – a parable
It was many years ago that villagers of Downstream recall spotting the first body in
the river. Some old timers remember how spartan were the facilities and procedures
for managing that sort of thing. Sometimes, they say, it would take hours to pull 10
people from the river, and even then only a few would recover.
Though the number of victims in the river has increased greatly in recent years, the folks of
Downstream have responded admirably to the challenge. Their rescue system is clearly
second to none: most people discovered in the swirling waters are reached within 20 minutes;
many less than 10. Only a small number drown each day before help arrives; a big
improvement from the way it used to be.
Talk to the people of Downstream and they'll speak with pride about the new hospital by the
edge of the waters, the flotilla of rescue boats ready for service at a moment's notice, the
comprehensive health plans for coordinating all the manpower involved, and the large
numbers of highly trained and dedicated swimmers all ready to risk their lives to save victims
from the raging currents. Sure it costs a lot but, say the people from Downstream, what else
can decent people do except to provide whatever is necessary when human lives are at stake.
Oh, a few people in Downstream have raised the question now and again; "What's going on
Upstream? Why are these bodies in the river at all?" But most folks show little interest in
what's happening Upstream. It seems there's so much to do to help those in the river that
nobody's got time to check how all those bodies are getting there in the first place. That's the
way things are sometimes.
Don Ardell
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When teeth are together they can break bones. Ankole proverb
When spider webs unite they can tie up a lion. Ethiopian proverb
Do not look where you fell, but where you slipped. African proverb
If you don't stand for something, you will fall for anything African proverb
Even the mightiest eagle comes down to the tree tops to rest Ugandan proverb
Who digs the well should not be refused water. Swahili proverb
“A new model is needed for research in developing countries. A model that promotes
locally applied research that enhances capacity and answers that arise from the
community. It could be called micro-research and be based, like micro-finance, on
small grants for those who have little access to funding opportunities.”
Jerome Kabakyenga, Dean, Mbarara, Uganda and Noni Macdonald, ed. CMAJ
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DECLARATION BY THE International Conference on Primary Health Care and
Health Systems in Africa, Ouagadougou, Burkina Faso, 28-30 April 2008
The Conference held in Ouagadougou, Burkina Faso from 28-30 April 2008, declare as
follows:
I. Deeply concerned by the many public health challenges that our continent is facing
including:
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XII. Recalling the declaration by the third ordinary session of the African Union
conference of ministers of health in Johannesburg in April 2007 urging Member
States to commit themselves to inter-ministerial collaboration for coordinated,
harmonized and comprehensive response to the health challenges that Africa is
facing;
XIII. Recognizing the link between health, poverty reduction, good governance, peace
and security, gender integration and global commitment to universal access to
PHC in order to facilitate the achievement of the Millennium Development Goals;
XIV. Considering that a healthy population is not only a development imperative but
also a wealth for African countries;
XV. Considering the scarcity of resources for health in African countries;
XVI. Recognizing that notwithstanding efforts by countries, there remain challenges
such as poverty, bad governance, low participation of communities especially
women in decision-making process, weaknesses of health delivery systems
including inadequacy of motivated and qualified human resources, limited
capacity in care provision, weak interface between the community and the formal
systems of health delivery resulting, very often, from lack of health awareness;
XVII. Recognizing that Africa will need to make increased efforts before it can achieve
the Millennium Development Goals;
XVIII. Aware of the multidimensional nature of health, the importance of, and need for,
intersectoral collaboration both internally and externally in order to improve the
health status of the populations;
XIX. Realizing the historic opportunity provided by the interest shown in, and
importance attached to, health as a factor of development.
The Conference:
1. Reaffirms the relevance and validity, today, of the basic principles
and elements of the Alma-Ata Primary Health Care Strategy;
2. Makes a commitment to promote systematically the involvement
and increased participation of communities in health development
in order to facilitate the achievement of the Millennium
Development Goals and improve the well-being of the peoples of
Africa;
3. Strongly recommends;
1. To governments:
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(d) To revitalize or establish an appropriate coordination mechanism that brings
together the inter-ministerial committee, national health committees and other
institutions with a view to harmonizing the complementary roles of the various
levels of the health pyramid;
(e) To incorporate, in their national and district plans, priority interventions for
revitalizing health services based on the PHC approach;
(f) To implement a programme of action to address the human resources for
health crisis including effective deployment, stimulation of better performance
and adequate response to brain drain;
(g) To strengthen planning and training with emphasis on public health,
employment and human resources management and retention;
(h) To allocate resources in an equitable and sustainable manner based on the
needs of the different levels of the health system;
(i) To promote intersectoral collaboration and public/private partnership including
civil society in order to achieve the Millennium Development Goals;
(j) To revitalize referral systems to support integrated district health services;
(k) To mobilize and bring together all development actors to enhance
cohesiveness and synergy in the choice and delivery of the planned
integrated services;
(l) To formulate strategic health financing policies and plans fitting into the
overall national development framework especially as regards medium-term
expenditure and poverty reduction;
(m) To ensure that the financing plan is included in the national socioeconomic
development plan;
(n) To promote health awareness among the population and strengthen the
capacities of communities to provide for their own health care and be more
involved in health activities;
(o) To ensure more effective monitoring, oversight and evaluation of health
activities;
(p) To promote operational research on health systems in a manner that will
facilitate evidence-based decision making;
(q) To establish mechanisms and conditions that would enable ministries of
health to perform their role of leadership, regulation and good governance;
2. To communities:
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(c) To do advocacy among members of the Diaspora for their effective
involvement in development activities.
3. To sub regional, regional and international partners:
(a) Governments should create, at national level, the conditions (meetings, laws,
regulations, etc.) needed to translate into concrete deeds the orientations
contained in the reference document and the recommendations of the
conference to improve the health status of the populations;
(b) Governments and partners should establish mechanisms to follow-up on the
recommendations of this conference;
(c) The WHO Regional Office for Africa should produce a report each year for the
Regional Committee and partners on the progress in the implementation of
the recommendations of the conference;
(d) Governments, in collaboration with partners, should document best practices
and encourage the dissemination and sharing of best experiences among
countries of the region;
15
CHAPTER 2
INTRODUCTION
The fourth millennium development goal (MDG) focuses on reduction of the under five
mortality. Many of the programmes that have contributed to the survival of the child
under five years have omitted the neonatal period. As a result 38% of all deaths in the
first 5 years are in this period. If we do not address the problems of the neonate we
are unlikely to meet the global goal improving child survival. Improved survival will thus
depend on investment in interventions that cater for newborn care. Within the neonatal
period the highest deaths occur in the first 24 hours (25-45%) and up to 75% of deaths
occur in the first 7 days. Many of these deaths are also related to the health of the
mother. This is the basis of continuum of care approach for mothers, newborns and
children (pregnancy, delivery and postnatal care).
Health care should start with the girl child ensuring adequate nutrition and growth
followed by cultural changes and life skills that enable the girl to prevent adolescent
pregnancy. All pregnant women should get good care during pregnancy and delivery.
The aim of care is to ensure intact survival of the mother and her baby. Many problems
in this period lead to permanent disability. Majority are predictable. Care starts in the
community but there should be a close liaison with the health facility. The SEARCH
project, India, Gadchiroli, provides a good example of a culturally appropriate, evidence
based community newborn care initiative from which many countries can learn, adapt
and replicate.
Though for child survival we tend to stress goal 4 of the MDG all other goals are equally
important. For you cannot improve child survival without reducing poverty (goal 1),
improving education and equity of women (goals 2 &3), maternal health (goal 5) as well
as reducing infections in the mother (goal 6) and environmental sustainability (goal 7)
Objectives
16
LEARNING ACTIVITIES
Definitions
Newborn (neonate)/neonatal period: age/period 0-28 days of postnatal life
Early neonatal period: 0-7 days of postnatal life
Late neonatal period: 8-28 days of postnatal life
Preterm baby: <37 completed weeks of gestation
Low birth weight (LBW): birth weight <2500g
Small for gestational age: birth weight <10th percentile for gestation
Perinatal mortality rate: stillbirths + 7 days postnatal deaths per 1000 births
Neonatal mortality: deaths in the first 28 days per 1000 live births
Delay/space pregnancies
Babies born to young mothers tend to die (most of these pregnancies are unplanned).
For healthy outcome for mother and baby the inter-pregnancy interval should ideally be
at least 24 months and preferably 36 months. There is thus a need to find ways of
providing family planning services to the majority of families
Nutrition
Pre pregnancy:
Ideal is to have a well nourished woman before start of a pregnancy. A stunted child will
lead to a stunted adult. Short women have difficulty deliveries. Micronutrient deficiency
especially folate may lead to neural tube defects.
During pregnancy:
Macronutrients predispose to LBW
Micronutrients (in particular iron, zinc, vitamin A, folic acid and iodine) lead to LBW, birth
defects, pregnancy losses, increased infections.
Infections
During pregnancy:
These may lead to foetal infections, intrauterine growth restriction, and preterm labour
or foetal loss
During labour and delivery:
Baby is likely to pick infection especially if there is prolonged rupture of membranes.
17
Maternal Education
This is key for access and utilization of health services as well as self care and care for
the baby.
This is a good entry point for health care. About 70% of women in Africa attend ANC at
least once during pregnancy. If 90% of women received good quality ANC up to 14%
newborn lives would be saved. It is important for health workers in the community to
know and record all women who are capable of becoming pregnant and to closely follow
up those who are actually pregnant. Women need to be encouraged to attend antenatal
care as early as possible.
Focused antenatal care aims to respond to the needs of pregnant women with
emphasis on:
18
PRINCIPLES OF NEONATAL CARE
Majority of babies do manage to establish breathing without help. That first cry is so
vital. It opens up the lungs with a high pressure. But when this does not happen we all
panic and may do more harm than good for the survival of the baby. Since asphyxia is
not always predictable preparedness is essential. All persons conducting a delivery
should be able to adequately resuscitate a baby.
Keeping the baby warm
All neonates need extra warmth at birth but care should be taken not to overheat them.
LBW infants, asphyxiated babies and all sick babies in general are at more risk than
normal term neonates.
1. At birth
Babies lose heat very quickly because they are wet at birth. Therefore dry them quickly
remove the wet towel and wrap in a dry one. Put the baby next to mother and if possible
initiate skin to skin nursing (kangaroo care). Delay bathing the baby till after 24 hours of
age. Initiate breastfeeding within 30-60 minutes of birth.
For preterm or low birth weight babies, continue with Kangaroo care to keep them
warm.
19
Preterm/LBW depend on size and whether well or sick. Well preterm do very well in
continued kangaroo care. Sick ones should be managed in a warmed up area. If there
is a good follow up programme these babies can be discharged fairly early.
In neonatal units heated rooms with a covered baby can be adequate to keep the
babies warm. Incubators are best reserved for sick neonates in large hospitals with
appropriate back up services. They are expensive, difficult to maintain and require
constant supply of electricity.
Prevention of infections
Clean delivery (clean hands, clean cutting and tying of the cord, clean cloths/towels for
wrapping the baby).
Appropriate cord care after delivery: Discourage harmful cultural practices; Use surgical
spirit until cord drops off and complete umbilical healing
Initiation of breastfeeding within the first hour of delivery
Reduce overcrowding at health facility partly by avoiding unnecessary admissions and
early discharge
Leave baby with own mother all or most of the time
Recognize infected baby and isolate them early. Although clinical features in an infected
newborn can be nonspecific, some of the danger signs include:
Fever or lowered temperature
Too sleepy or hard to awaken
Refusal to feed or feed intolerance
Fast breathing and or chest in drawing
Pus or redness in the umbilical cord and or eyes
Breastfeeding
Initiation of breastfeeding within the first hour plays a major role in neonatal survival. As
we have seen above it helps to prevent hypothermia and infection. It also helps to
establish good breast milk supply and thus the baby will be well nourished from the
start. Babies are born with good reflexes (rooting and sucking) for survival and are able
to regulate their intake to satisfy normal growth. They will demand to be fed when
hungry. If a baby does not demand a feed it usually means he is sick or immature.
It is estimated that in Africa 14% of all babies born are LBW. These babies are either
born too early (preterm) or suffered poor growth in utero resulting from complications
during pregnancy. Preterm babies contribute to about 28% of all neonatal deaths.
Paying attention to their care will thus reduce neonatal mortality. The most vulnerable
are the babies weighing <1500g at birth and < 33 weeks gestation. They have problems
of breathing, feeding and maintaining body temperature and have a higher mortality
than the bigger LBW infants. These very low birth weight (VLBW) are best looked after
in a referral hospital.
20
As mentioned under “keeping babies warm” the LBW over 1500g can easily be kept
warm using kangaroo care method unless they have additional problems. They may
need stabilization for some time in a neonatal unit before being fully transited to
kangaroo care and finally discharged into the community.
This is an area often neglected in a busy health care facility. Imparting knowledge to the
clients is often relegated to the most junior staff and sometimes a student. This should
be a dialogue rather than talking down to the client. All through care information from
the client needs to be discussed so that the client understands what is going on. If a
problem occurred it should be discussed as to how it can be avoided in future. Parents
should be encouraged to seek appropriate care early. The need for continued care at a
health facility should be communicated as well as what will be done.
POSTNATAL FOLLOW UP
Most mothers with normal delivery are discharged from a health facility within 24-48
hours of birth while it is also known that most neonatal problems appear in the first week
of delivery. It is therefore important to plan an early follow up. Depending on the health
care set up in the area this can be a home follow up or at health facility. The first visit is
often planned within 7 -14 days. The earlier the better. At this time it is important to
check:
Adequacy of feeding
Cord/umbilicus for possible infection
Weight gain – should be back to birth weight
The mother should be encouraged to report any concern about the baby as soon as
possible
Infections
21
Where community based newborn care programmes exist, training of community based
agents to identify infection and other danger signs in the baby and refer and or provide
care such as antibiotic will save newborn lives.
Preterm babies
Maternal nutrition: adequate intake of both macro and micro nutrients
Improve ANC screening and management of pregnancy complications
Careful care from birth to prevent infections, adequate feeding and kangaroo care when
feasible
Perinatal asphyxia
Screening in pregnancy for those mothers likely to have cephalo-pelvic disproportion
Birth preparedness
Emergency obstetric preparedness and prompt referral
Skilled attendant at delivery for care of the newborn baby
This is based on the continuum of care recognizing that most deaths occur at home
during child birth and in the first few days post delivery. Integration into and
strengthening existing services is important. Often reproductive services omit care of
the neonate. But many IMCI programmes have added the ‘N’ (newborn) and ‘C’
(community). In built in this is avoiding of delays – delay in recognition of problems;
delay in transport to reach appropriate care; delay in executing care at the health
facility.
Supportive government policy and planning is needed. Aim at improving health care
systems at all levels. All facilities conducting deliveries should provide essential
newborn care including neonatal resuscitation, care of the moderate low birth weights
infants and establish a good workable referral system.
LEVEL 1: HOME/COMMUNITY
22
great deal can be done at this level if good training, equipping and supervision is
provided.
Birth preparedness is important so the community must plan for emergency transport to
the nearest health facility.
Staff: Primarily run by nurses, midwives, and clinical officers (medical assistants) Some
have basic laboratory services requiring a laboratory assistant. If available a nutritionist
would be desirable.
Duties:
Supervision and education of the community health worker
Health care delivery service to the surrounding community
They should be able to:
Provide antenatal care and delivery services to women within the catchment area
Deal with simple problems in pregnancy labour and delivery
Resuscitate a new born baby (All workers)
Do routine tests for antenatal mothers
Identify and initiate treatment in conditions that require hospital care
Supervise care of the neonate in the community
At all times the health care provider should be asking two questions: one - am I trained
to deal with the problem at hand? two – do I have the equipment or supplies to deal
with the problem? If the answer is “NO” to either of these the mother/baby should be
referred to the next station that is able to handle the problem.
Staff: Doctors, nurses, midwives, clinical officers laboratory technologists (in some
countries obstetricians and pediatricians may be available)
They should be able to provide comprehensive emergency obstetric and neonatal care.
There should be good communication with all the dispensaries and health centres within
the district.
23
Collect analyze useful information and plan for intervention at different levels
Have a good triage system that will recognize emergency neonatal problems
This can be a provincial or a teaching hospital (in some countries the teaching and
referral hospitals are graded higher than a provincial hospital)
All levels of specialists preferably with neonatologists and neonatal nurses are usually
available.
There should be good diagnostic services.
They would be responsible for
Care of normal cases within the catchment area of the hospital
More specialized care
Training of all cadres of health care workers
Supervision and liaising with staff in the lower hospitals
Operational research (especially for teaching hospitals)
BEYOND SURVIVAL
Many babies survive the neonatal period but remain with disabilities that could have
been prevented. These should be minimized and if they do occur intervene early.
REFERENCES
The Lancet 2005: Series on neonatal survival Vol. 365 pages: 821-26, 891-900, 977-
988, 1087-98
THE PARTNERSHIP: Opportunities for Africa’s Newborns. Practical data, policy, and
programmatic support for newborn care in Africa
WHO World health report 2005: Make every mother and child count
Home based care for Mothers and Newborns-A Facilitator Guide for training community
Baseline Knowledge Attitude and Practice Survey for the Community Based Newborn
and Maternal Child Health Initiative in Zambia, MP Shilalukey Ngoma, P Kalesha, RK
Mbewe, Tesfaye Shiferaw, RK Mwale, W. Mutale, C. Chabala, C Michelo, S.Sizya, K.
Mwinga, N Mugala, G Gundumure, D Kaluba Chinyama, D Mumba and V Mukonka.,
UNICEF /MOH Zambia, 2008
24
CHAPTER 3
INTRODUCTION
IYCF covers the feeding of the child for the first two years of life. Children have the right
to adequate nutrition as stated in the Convention on the Rights of the Child. For the
young child this means exclusive breastfeeding for the first six months and continued
breastfeeding for two years together nutritious complementary foods.
Malnutrition is directly and indirectly associated with increased morbidity and mortality of
infants and young children. Inadequate feeding in the early years is a major contributor
to poor economic development. Metabolic programming which is defined as a stimulus
or insult applied at a critical or sensitive period in development, could have long term
effect on structure or function of the organism. Early nutrition has a great impact on a
number of body systems and of critical importance is the brain growth. Brain growth is
highest in foetal life; by the age of 1year it is 60% of adult brain size and by 2 years of
age it is 80%. Poor nutrition in these periods leads to irreversible changes that cannot
be corrected by better nutrition later in life when the effects manifest as suboptimal
education performance and reduced lifetime earnings by >10%. Good nutrition
therefore protects foetus, infant and young child from permanent physical and
intellectual stunting.
Goal 5: Improve maternal health: Reduce maternal mortality rate by three quarters
This goal does not address maternal nutrition as an indicator but we know that maternal
malnutrition contributes to maternal deaths as well as early childhood nutrition
25
OBJECTIVES
LEARNING ACTIVITIES
Visit an antenatal clinic and carry out breast examination with special emphasis on
anatomical variations of breasts and nipples
Visit an antenatal clinic and interview a pregnant woman on knowledge, attitude and
planned practice on breastfeeding and assess the baby friendly hospital initiative (BFHI)
activity of the clinic
Counsel a mother on importance of breastfeeding
Counsel a mother on how to practice exclusive breastfeeding
Visit a postnatal ward and practice positioning and attachment of a newly born baby on
the breast
Visit a newborn nursery (special care unit) and assist in the breastfeeding of sick a baby
Visit a child health clinic and counsel a mother returning to work after maternity leave on
feeding
Visit a local breastfeeding support group and write a report on its activities
Visit a prevention of mother to child transmission of HIV (PMTCT) programme and learn
how to counsel on feeding options for an HIV infected mother.
Take an infant and young child feeding history
26
Complementary feeding: Other foods or liquids provided along with breast milk.
Complementary food: Any nutrient –containing food or liquid given along with breast
milk during the period of complementary feeding.
Transitional foods: Complementary foods especially designed to meet the nutritional
needs of young children.
Family foods: Complementary foods that are the same as those consumed by rest of
the family
Weaning: Putting a complete stop to breastfeeding.
BREASTFEEDING
Advantages of breastfeeding
If the mother exclusively breastfeeds and feeds several times a day and night she can
be protected from another pregnancy. Child spacing favours child survival.
Mother also benefits from breastfeeding as they have reduced risk of postpartum
haemorrhage, breast and ovarian cancer.
The breast is composed of the main body, areola and the nipple. In the main body are
glandular tissues (alveoli) several of which drain into a milk (lactiferous) ducts. These
ducts dilate in the areola and are known as lactiferous sinuses which finally open into
the nipple. Each alveolus is surrounded by smooth muscles. Milk glands and ducts are
27
supported by fat tissue and it is this fat that is mainly responsible for the size of the
breast. There is also a good blood and nerve supply.
The areola and nipple contain smooth muscles. Each nipple has 15-25 openings. The
areola contains several sebaceous glands (Montgomery glands) which secrete a
substance that has antibacterial and lubricating properties. There is a rich nervous
supply. The skin of the areola and nipple is much darker than the rest of the breast. The
sizes of both the areola and nipple vary in different women.
28
Physiology of lactation
Preparation of the breast for lactation: During pregnancy there is proliferation of the
ducts and alveoli under the influence of pregnancy related hormones: oestrogen,
progesterone, human placental lactogen (HPL) and human chorionic gonadotrophin
(HCG).
29
Figure 2. Prolactin reflex
Human milk is tailored to the needs of the baby. It contains proteins, carbohydrates,
fats, vitamins and minerals in forms that are easily digested and assimilated by the
baby. Though composition is divided into stages the changes during the first two weeks
of lactation are gradual. However the first 5 days milk is known as colostrum it passes
through a transitions period and finally becomes mature by 14 days.
Colostrum: a thick yellowish fluid containing less lactose but more protein, fat, fat
soluble vitamins and minerals than mature milk. It is rich in immune factors especially
immune globulins.
30
Mature milk: composition and comparison with other types of milk is shown in table 1.
Water: is the largest constituent in which all constituents are dissolved, dispersed or
suspended. There is enough water that supplies all that the baby needs in the first 6
months of exclusive breastfeeding even for those that live in very hot climates.
Proteins: Milk proteins are subdivided into casein and whey proteins. The caseins are in
the solid fraction when milk cuddles while the whey proteins remain in the fluid fraction.
Caseins are difficult to digest especially for the young infant. Hence in human milk the
casein: whey ratio starts low at 80:20 but later in lactation changes to 40:60. Mature
cow milk on the other hand has high casein: whey ratio of 80:20.
Fats (lipids): About 30-35% of infant’s daily energy is provided by fats. Most of the milk
fat is in the hind milk. So if the baby does not empty the breast total energy intake may
be low and the baby will fail to gain weight. Human milk has polyunsaturated to
saturated ratio of 1.3:1 while that of cow milk is 1:4. Human milk is rich in the essential
lipids (linolenic and linoleic acids) that are important in brain development.
Carbohydrates: the main carbohydrate in breast milk is lactose although small amounts
of other sugars such as glucose are found. Human milk has higher lactose
concentration than other mammals. Lactose is metabolized into glucose and galactose
which is important in brain development. Lactose facilitates calcium absorption, and
promotes growth of lactobacillus bifidus.
Micronutrients and minerals: Concentrations of these are adequate for the baby
especially in the first six month of lactation. However if the mother is deficient in
micronutrients there may be deficiency in the baby. About 50% of iron in human is
absorbed versus 10% in cow milk.
Digestive enzymes and growth promoters
Human milk contains digestive enzymes and one of the most well described is lipase an
enzyme that facilitates fat absorption.
There are growth factors that promote maturation of the brain and epithelial surfaces.
Molecules similar to those found in breast milk have been developed into drugs to treat
bone marrow failure.
31
Immunologic qualities of breast milk
Babies are born with an immature immune system and rely of passive immunity from
their mother received through active transfer of immunoglobulins in the last trimester of
pregnancy and through breast milk especially colostrum. The latter is often referred to
as baby’s first immunization. During pregnancy there is active migration of immune
competent cells to the breast where they manufacture anti-infective factors based on
the mother’s experience. Breast milk has a wider repertoire of anti-infective factors
compared to mother’s plasma. The anti-infective factors include antibodies, soluble
components like lysozyme, lactoferrin, lipids and milk fat globules as well as live
leucocytes that protect the baby from infection. The components that are there for
protection /information are not digested/ destroyed as they traverse through the
gastrointestinal tract. Breast milk macrophages home in to the Peyer’s patches where
they help promote infant gut mucosal related immunity and in the process may confer
cell mediated immunity. Thus breast milk is unique in prevention of infection. (1) There
is no risk of contamination; (2) there are several anti-infective properties; (3) it induces
immune competence in several body organs (4) it induces maturation of the gut (5)
faster gastric emptying. As long as baby and mother have close contact, mother will
form protective agents or antibodies against any organism on the baby. Baby will
always be protected as long as s/he gets own mother’s milk. But the protective effect
is dose dependent—exclusively breast fed are most protected; partially breast fed are
better off than those who are not breast fed.
MANAGEMENT OF LACTATION
Prenatal period:
Successful breast feeding depends on knowledge, skills and practice of the health
worker as well as the mother/ parents. Mothers/ parents decide on how to feed their
babies during pregnancy or even before. Decisions are often dictated by observation or
culture. However parents should be given the necessary education to enable them
to make a fully informed choice. The aim of the education is to help them breast feed
optimally and avoid difficulties .Building confidence at this stage is advantageous.
It is important to remember that there are many normal variations in shape and size of
breast and nipples. Elasticity of the nipple always improves towards delivery time. There
is no need for nipple preparation even when there is inversion. Hoffman exercises and
breast shells have shown no proven value. Rubbing, rolling and pulling are not
32
recommended- they might even induce premature labour through increased oxytocin
release.
Maternal nutrition: assess nutritional status and discuss with the mother on the
importance of an adequate diet for her and her unborn baby. Work out ways how she
can achieve this using locally available food. Pregnant women are not able to meet
their micronutrient needs and therefore will benefit from supplementation with multi-
mineral-vitamin mix. Of note anaemic women are at increased risk of pregnancy related
haemorrhage, preterm and low birth weight delivery. Explain why she may need
supplementation
Benefits of breast feeding: start from what the mothers know and fill in the gaps.
Importance of early initiation: discuss why this is necessary and what will happen in
the delivery room in relation to breast feeding. Initiation should be within the first 30-60
minutes of birth. Early initiation is associated with good milk flow and helps to prevent
infection in the newborn. In the first 60 minutes after a delivery, the baby is alert.
Breastfeeding during this period improves attachment and is associated with longer
duration of breastfeeding.
Positioning and attachment: Demonstrate and discuss how this will help prevent
problems such as nipple pain, trauma (crack) and since it ensures adequate breast
emptying it also prevents engorgement. If attachment is on the nipple and not on the
areola, the milk does not flow, resulting in a frustrated baby. Then the baby sucks
harder and the mother ends up with cracked nipples.
Importance of exclusive breast feeding for 6 months: Exclusive breastfeeding means
giving breast milk only, and no water or prelacteal feeds. In the early period many
mothers worry that there is not enough milk. Please assure mothers that the colostrum
is adequate for the infant and early initiation helps milk flow. Mother who have to go
back to work need to plan how they will sustain exclusive breastfeeding. Breast milk is
safe for 3 months if frozen, 72 hours in the fridge and 8 hours at room temperature.
Show mothers how to express breast milk and to develop a plan that best suits them
which may include carrying the baby back to work. Remind them that expressed breast
milk is safe and other people will not be tempted to share it with the baby.
How to assure enough milk: this is achieved through early initiation and on demand
feeding. The more the breast is emptied, the more milk produced. Thus expressing
breast milk if separated from the baby supports sustenance of the supply.
33
Perinatal and immediate postnatal period
PROBLEMS IN BREASTFEEDING
Is the baby growing well? If ‘yes’ reassure; if ‘no’ then ask the next question:
How is the positioning and attachment? – If not appropriate then the baby may actually
be starving because he is not able to get the breast milk out of the breast. If ‘yes’ then
go to the next question:
34
How often is the baby’s nappy/diaper changed? This can be an indication of amount of
urine passed. If frequent (6-8 times) then breast milk is adequate and therefore
reassure the mother. If less frequent then explore further by asking:
What is her confidence that she can have enough milk? If she has enough confidence
then counsel and encourage her mother to continue exclusive breastfeeding and stop
any supplement if she had already started. If she lacks the confidence then counsel her
on how to ensure adequate breast milk supply.
Other conditions that may lead to a perception of not having adequate milk –
Periods of growth spurts are associated with increased frequency of feeding. In this
case reassure the mother.
Mothers often associate a soft feeling breast with inadequate milk. This is the normal
texture of the breast and she should be reassured that she has enough milk.
Mastitis is an infection of the breast that could lead to abscess formation. It commonly
occurs in the second or third week postpartum. It is managed with antibiotics,
analgesics, warm packs and frequent emptying of the breast. If an abscess develops
then incision and drainage should be done in addition to antibiotics.
Cracked nipples: The best management of this is prevention. However if it occurs keep
the nipple dry by exposing it to air; mother can express breast milk and apply it on the
nipple; check for evidence of infection especially candida. The mother may be having
vaginal candidiasis. If there is candida infection then make sure you treat both mother
and baby at the same time. Show mother how to correctly position and attach baby and
encourage frequent breastfeeding.
Flat or inverted nipples: After delivery the mother can now be shown how to pull out
the nipples and attach baby properly. Mothers with truly inverted nipples need more
help. Use of a 20ml syringe can be useful. Remove the plunger and cut off the needle
end making a smooth margin. The mother can the use this to apply negative pressure
which helps to pull out the nipple just before each feed.
COMPLEMENTARY FEEDING
Age 6-24 months is considered the period of complementary feeding. Timely and
appropriate complementary feeding will reduce mortality; prevent weight loss and more
so stunting. This period can be managed well if accurate information and skilled support
35
for the family is provided. More often than not inadequate knowledge about appropriate
food rather than lack of food is the cause of malnutrition.
Oral-motor development function during the 0-6 month period is designed for liquid
feeding i.e. breast milk. In the second half of the first year jaw and tongue movement,
together with the appearance of teeth equip the baby for other foods other than milk.
These continue to develop during the second year by the end which the primary
dentition is also completed.
Digestion and absorption of complex carbohydrates and fats is suboptimal during the
first 6 months but as the baby grows these improve to allow baby to take a variety of
foods.
Excretory system: Renal function – ability to excrete excess limited. Breast milk has a
low solute load to the kidney.
Nutritional needs: It is now well established that babies have adequate growth up to 6
months without complementary foods. But by 6 months breast milk ceases to give
enough nutrients to babies hence the need to start complementary feeding.
A baby who is ready for complementary feeds will want to breastfeed more frequently.
The stool will decrease in volume and may have green streaks in it. The first step
would be to breastfeed the baby more frequently and if the increased milk supply is still
not sufficient complementary feeds should be introduced. Breast milk is adequate until
6 months of age.
Physiological stress
Incomplete digestion –may lead to sensitization; diarrhoea
Malnutrition – both over & under nutrition can occur
Micronutrient deficiency
Generally a negative impact on health.
Very often people talk of a balanced diet when counseling on complementary feeding. It
is important to define what you mean by this. To some people it means taking the
necessary food groups without thinking of quantities. Perhaps we should be talking
36
more in terms of adequacy—this implies that the quality as well as the quantity as
considered.
Whatever you add displaces milk. Whatever you add is most often of lower nutritional
value than milk
Children continue to need breast milk therefore mother should continue breastfeeding
on demand. In the 6-12 months milk should make up to 70% of child’s diet.
Babies of HIV infected women who are weaned at 6 months need animal source
proteins in their diet to meet all their nutritional requirements. Therefore a non
breastfeeding baby requires a minimum of 500mls of other milk through the 6-24 month
period. In poor communities this may be difficult resulting in malnutrition. An AFASS
assessment should be carried out before a mother weans her baby.
Give a variety of foods taking into account the nutrient content of the food used.
Active feeding i.e. assist the child to eat but do not force feed. Talk to the child and use
the meal times as an opportunity for psychosocial stimulation. In the period 9-15months
babies go through a stage of recognizing themselves as autonomous from the mother
and may refuse to eat. Active feeding then becomes a very important strategy of
ensuring adequate nutrition.
Avoid excessive amounts of food. Fat cells are made in the first 18 months of life and
obesity in this period is associated with the same in adulthood.
Food hygiene is very important. Stress hand washing; clean containers; food should be
freshly prepared or fully boiled every time the child is to be fed
Significant progress has been made in defining infant feeding practice in the context of
HIV.
Exclusive breastfeeding is the best option for infant feeding for HIV uninfected mothers.
Even in high HIV prevalence regions the majority of women are not infected. Therefore
promotion of exclusive breastfeeding is good public health practice and is an incentive
for women to avoid infection.
37
It is true breastfed babies of HIV infected women are at risk of infection as long as they
are breastfed. This risk is particularly high in women who are newly infected, women
with advanced HIV disease and those with breast disease (cracked nipples, mastitis
etc.) Without intervention up to 20-45% children got infected. The estimated contribution
of breastfeeding is 14-15%.
Replacement feeding will prevent transmission, but is not a safe intervention for the
majority of mothers. Therefore wholesale promotion of formula feeding for HIV
exposed babies is dangerous and bad public health practice.
Exclusive breastfeeding -
Good attachment techniques to minimize cracked nipples
Prompt treatment of breast disease and use of heat treated breast milk during such
episodes
Early weaning as soon as a mother is able to provide nutritionally adequate
complementary feeds. Early cessation of breastfeeding ( <6mo) may reduce HIV
transmission but it increases risk of morbidity & mortality (malnutrition, diarrhoea,
pneumonia). HIV infected infants have better survival if breastfed beyond 6 months.
Replacement feeding for women meeting AFASS
The health worker has a moral and ethical obligation to promote appropriate infant
feeding practice. In order to do this, they must help the HIV infected parents make an
assessment of the ‘balance of risks’ with the goals being a living HIV free infant.
The most recent research shows that HIV free survival of infants of mothers who are on
efficacious ARV regimens for PMCT are similar for breastfed and formula fed infants. In
resource constrained settings breastfed infants of women receiving HAART have better
HIV free survival at 12 months of age compared to formula-fed infants.
38
Parents have a right to choose the best feeding option for their child. This should be
based on clear, adequate and unbiased information from a knowledgeable health care
worker. Once the decision has been made, the health worker continues to support and
guide the parents on how to safely practice the chosen method.
As early as 1987 the world health organization’s (WHO) stand has been that the choice
of infant feeding “should take into consideration the socio-economic and ecological
environment of the mother/infant pair and to the extent to which alternatives can safely
and effectively be used.” Subsequent consensus statements from
WHO/UNICEF/UNAIDS/UNFPA have endorsed the same sentiments. The latest
statement of 2006 has the following recommendations: “The most appropriate infant
feeding option should continue to depend on the mother’s individual circumstances;
exclusive breastfeeding is recommended for the first six months of life unless
replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS);
when there is AFASS then avoidance of all breastfeeding is recommended.”
From this statement we can see that there are two options in the first six months namely
exclusive breastfeeding or exclusive replacement feeding. From six months all infants
should receive complementary foods.
All health workers providing services to pregnant women and mothers of young infants
should provide this counseling and support.
Remember to inform the parents that there is no particular intervention in an HIV
infected parent that will reduce transmission to zero otherwise they get very
disappointed when they do everything possible and still end up with an infected child.
Adherence & longer duration of optimal infant feeding practice can be achieved through
high quality counseling. Exclusive breastfeeding is not the norm in most part of sub
Sahara Africa and therefore all mothers need infant feeding counseling support to
achieve best practice. Health workers should avoid stigmatizing exclusive
breastfeeding.
Beliefs/culture:
Ask specifically about use of water, juices, and other milks.
Any other hindrances that may have significant influence on breast feeding.
39
If not breastfeeding ask why? What other milk is she giving and how does she prepare
it?
Is the child taking any other food or milk? If yes you will want to know what food,
how it is prepared, the amount and frequency and how it is fed to the child. A 24 hour
food recall is often used and if possible food frequency e.g. in a week helps to judge
adequacy of diet.
SUPPORT SYSTEMS
All mothers need a conducive environment that will help them achieve optimal feeding
of their infant and young children. Support will come from: father and immediate family;
community; health professionals and their professional bodies; government and
partners; all working together for the betterment of child survival.
40
Community breastfeeding support group
This could be a group purely for breastfeeding activities but for sustainability purposes it
may be better to incorporate other activities the group may want to address. Both IMCI
and BFHI strongly recommend community support with the realization that IYCF is
actually a community activity. Health workers at facilities should be knowledgeable on
the activity of the community and work with them for health promotion. If there is no
active community support for breastfeeding then the health worker is encouraged to
start one. But it is very important that the community own the group the health worker
just being an expert advisor. Here experienced and knowledgeable (check accuracy of
this knowledge) women help to support breastfeeding mothers through dialogue and
sharing. The role and support of men and fathers is emphasized. Community support
leans heavily on advocating for behaviour change.
“ The global strategy includes as a priority for all governments to ensure that the health
and other relevant sectors protect, promote and support exclusive breastfeeding for six
months and continued breastfeeding up to two years or beyond, while providing women
access to the support they require – in the family, community and workplace to achieve
this goal”
41
REFERENCES
42
CHAPTER 4
CHILD NUTRITION
INTRODUCTION
Good nutrition is essential for satisfactory physical growth and mental development,
provides reserves for stress, as well as prevention of acute and chronic illnesses.
Compromised nutrition during childhood has lifelong effects on the well being of
individuals. The window of opportunity for prevention of these effects is during
pregnancy and the first 2 years of life. After two years, malnutrition will have caused
irreversible damage.
Under nutrition underlies 3.5million child deaths annually. The risk of death increases
with severity of malnutrition. Seven of 10 countries having the highest under-five
mortality are in Africa and include Democratic Republic of the Congo, Nigeria, Ethiopia,
Uganda, Tanzania, Madagascar and Kenya.
This chapter will outline the essential nutritional requirements of children, causes of
malnutrition, discuss the proven effective public health interventions and address the
management and prevention of common nutritional disorders.
OBJECTIVES
LEARNING ACTIVITIES
Visit a well child clinic and assess the nutritional status of a child who is growing
well and find out how she is managing to feed child well
43
Identify a child who is not growing well and counsel of adequate feeding using
foods available to the care give
Participate and write up the care of a child with acute severe malnutrition. Give
nutritional advice
Assuming you are visiting a primary school plan a group discussion with
the children. You can do this with your peers acting as school children
Plan a diet for a 7 year old HIV infected child who is having moderate
malnutrition
Water
Water requirements will vary with environmental temperature, activity and caloric
consumption. Daily requirements are 60-100mls/kg at birth and increase with age to
150mls/kg/day by end of the first week of life. Exclusively breast fed babies do not
require extra water as breast milk contains 80-90% water.
Carbohydrates
These provide the main source of energy for body functions. Daily intake should be
about 60 grams per 24 hours (0–6 months) and up to 130 grams per 24 hours at 3
years. Dietary sources include breast milk, sugar, and cereals such as maize, wheat,
oats, millet, starchy roots and fruits.
Fats
Fats have high energy and form an important energy store. They help to absorb fat
soluble vitamins. About 30% of the total energy required should be derived from fats.
Foods rich in fat include oils, margarine, butter, fish, meat, chicken, cheese, groundnuts
and soy bean. It is best to use vegetable fats (oils) as they generally contain
unsaturated fats which are better for the body than saturated ones.
Protein
Proteins are essential for growth and repair of tissue cells, synthesis of haemoglobin,
enzymes and antibodies. Important sources of protein include milk, eggs, fish, poultry,
cheese, soybeans, peas, lentils and nuts. Breast milk is the single most important
source of protein during infancy.
Vitamins
These include Vitamins A, B group, C, D, E and K and are also known as
micronutrients. These are consumed in small quantities and they have varying
physiological roles in the body. Important sources of vitamins include milk, vegetables,
grains, fish, liver, nuts and fruits
44
Minerals and trace elements
Also grouped under micronutrients, these include sodium, potassium, calcium,
magnesium, zinc, iron and iodine consumed in small quantities but essential for the
healthy functioning of the body. These are present in most foods mentioned above.
Energy requirements
Children require energy for growth, physical activity, basal metabolism and heat
production. The energy requirements vary depending on the age and activity of the
child. The average requirement for the first year is about 80-120 kcal/kg/day and
decreases in the subsequent years but increase during adolescence. Each gram of
protein or carbohydrate provides 4 kilocalories whereas a gram of fat provides about 5–
9 kilocalories.
NB 1 serving = 1 whole fruit, 125mls of juice, 1 eggs, 30g of meat, 150g of fish, 1 cup of
cooked rice or ugali, 1 chapatti, 1 slice of bread, 1 medium potato, 1 medium glass of
milk, 1 cup leafy green vegetables, ½ cup cooked vegetables, ½ cup cooked legumes
(peas, beans), 2 table spoonfuls of nuts, etc.
Ideally these foods should be packaged into 3 main meals and 2 snacks.
45
Meat-important sources of iron and zinc minerals, high quality protein. Spinach and
legumes are also very good sources of iron.
Mixing legumes with cereals is desirable e.g. maize and beans. Legumes are deficient
in methionine and rich in lysine while grains are deficient in lysine and rich in
methionine. Therefore eating either at the same meal or during the same day gives a
very good source of proteins comparable to consumption of animal protein. Legumes
need to be cooked thoroughly to increase bioavailability of these nutrients. If they are to
be prepared for complementary food for babies they should be pre-cooked before
milling.
Adolescents
This is a period of increased nutrient needs, but in the background of peer pressure,
consciousness of physical body image and media makes adolescence quite vulnerable
to malnutrition. They should be encouraged to feed well according to the food pyramid.
In resource constrained settings few children are able to achieve the above
recommendations. The biggest challenge is to achieve adequate intake. In addition the
children have to walk long distances to and from school and are likely to go to school
hungry. Also for part of the time the children are in school and parents may be unable to
influence what the child eats. Teachers therefore are also important especially if food is
provided by the school.
On the other hand there are increasing numbers of children from affluent families who
are beginning to suffer from obesity and for whom these guidelines will help prevent
further progression.
46
Pregnant and lactating women should be well catered for
Adequate breastfeeding and complementary feeding.
Share food well so the small children are not competing with older family
members
Encourage diversity of foods eaten within the household
Good preparation to prevent loss of nutrients
Teach school children and adolescents about good eating habits, how to prepare
and store food
Work with school teachers to ensure good feeding while children are in school
Early and adequate care /treatment of illnesses
Growth monitoring especially of young children. The growth chart easily picks out
those growing well, or not thus enabling early interventions to forestall
progression to severe malnutrition
NUTRITIONAL DISORDERS
Definition
Malnutrition is broadly categorized into under-nutrition and over nutrition (over weight
and obesity). Under nutrition encompassed stunting, wasting, deficiencies of vitamins
and minerals (collectively referred to as micro-nutrient deficiencies).
Indicators of malnutrition
Hunger, the feeling of discomfort from not eating is a good indicator of food
security. One of the Millennium development goals is to reduce by half the
number of people who suffer from hunger.
Low birth weight and intra-uterine growth retardation are measures of intra-
uterine growth restriction.
Maternal short stature and low body mass index during pregnancy and lactation.
The learner should review the chapter on growth monitoring for a detailed
discussion on the anthropometric techniques.
(i) immediate,
(ii) underlying and
(iii) basic causes.
47
Underlying causes include inadequate care of children and mothers, household food
insecurity, unhealthy household environment and lack of health services.
Basic causes are related to poverty, unequal distribution of resources at local, national
and international level. Health workers are best placed to deal with the immediate
causes of malnutrition, and these will be the focus of this chapter.
DALYS combine years of life lost due to premature death with years of life lived with
disability into an indicator that allows assessment of total loss of health from different
causes. One DALY is roughly one year of healthy life lost. The nutrition conditions that
are included in the analysis are protein energy deficiency, iron deficiency, vitamin A
deficiency and iodine deficiency. These estimates may under-estimate the impact of
nutrition on health and disease because under-nutrition has a synergistic effect with
many infectious conditions that lead to child death.
Table 2 is based on a global analysis that set to determine the impact of under-nutrition
on child mortality and disability with the latter measured as proportionate contribution of
the condition to the disability adjusted life-time years. This analysis based on
demographic data from countries of all regions of the world was that maternal and
under-five malnutrition is the underlying cause of death for 3.5million children annually,
35% of the burden of disease among children under five years of age and 11% of the
total DALY’s.
48
Low birth weight
Low birth weight contributes to increased mortality from asphyxia, and infections
(pneumonia, diarrhoea and sepsis) which account for 60% of all neonatal mortality.
Interventions that affect mother and child nutrition can be categorized into interventions
that have sufficient evidence for universal implementation and those that are beneficial
in specific situations. The interventions are categorized into those that impact maternal
and birth outcomes, interventions for newborn babies and interventions for infants and
children. The interventions include general nutrition interventions, micronutrient
supplementation and disease control interventions. Up to 25% of the DALY’s can be
49
averted through comprehensive nutrition interventions. The four most effective
interventions are breastfeeding promotion, which would result in a 9.1% reduction in
mortality and 21.9% reduction in stunting followed by vitamin A and
zinc supplementation and balanced energy supplementation in that order as shown in
table 4 below
Maternal under-nutrition has little effect on the volume or composition of breast milk
unless the mother is severely undernourished. But micronutrient content of breast milk
is dependent on the intake and nutritional status of the mother and therefore
micronutrient supplementation of the lactating woman is a strategy of ensuring
adequate supply to the baby.
Vitamin A deficiency
Vitamin A helps to maintain the integrity of cells on body surfaces and to form retinal
pigments and to destroy toxic products that cause tissue damage during infection.
Children with vitamin A deficiency are prone to respiratory infections and diarrhoeal
diseases. It is the commonest cause of blindness (xerophthalmia) in children. Vitamin A
deficiency is a public health problem affecting about 10 million children every year.
A child with any sign of xerophthalmia, measles, diarrhoea and severe malnutrition
should receive oral vitamin A on day 1, day 2 and repeat after 2-4 weeks. Children with
corneal lesions should be treated immediately or referred urgently as an hour’s delay in
treatment can lead to loss of sight.
The doses are:
Infant <6 months old: 50,000 IU
Infant 6-11 months old: 100,000 IU
Child 1-5 year old: 200,000 IU
Zinc deficiency
A trace element that is essential for growth and development of infants/children. The
main source of dietary zinc is meat, eggs, nuts, seeds and grains.
Zinc deficiency alters taste and smell; increases risk of diarrhoea, pneumonia and
malaria; growth retardation; and delayed wound healing. Zinc supplementation is
50
recommended in treating diarrhoea malnutrition and in chronic liver disease. The dose
of zinc during treatment is 2-3mg/kg/day
Using the above criteria all the countries in sub Sahara Africa other than Zimbabwe,
Botswana and republic of South Africa are classified as having a high risk of Zinc
deficiency.
Iron deficiency
Up to 40% of pregnant women and children worldwide have anaemia, 60% of which is
nutrition related. In children peak of iron deficiency is 18 months.
The main cause of iron deficiency anaemia is lack of animal source foods (fish, meat, or
poultry) in the diet.
Iron deficiency increase risk of mother’s death and affects children’s cognitive function.
The lower the haemoglobin, the higher the consequences of these conditions. There is
some evidence that iron supplementation has some benefit on IQ. Iron supplementation
is not recommended during an attack of malaria endemic regions where increased child
mortality was reported following iron supplementation.
Iodine deficiency
Iodine deficiency manifests with enlarged goitre, congenital hypothyroidism and
developmental disability. Traditionally these conditions have been used to assess the
prevalence of iodine deficiency. Newer methods include concentration of iodine in
urine.
Iodine deficiency during pregnancy impairs motor and mental development of the foetus
and increases the risk of miscarriage and foetal growth restriction. The best prevention
is use of iodized salt.
Calcium deficiency is the leading cause of rickets in sub Sahara Africa. Lack of
exposure to sunlight and the relatively infrequent use of vitamin D supplements leads to
development of rickets. In-utero vitamin D deficiency can be associated with poor
growth and bone mineralization which is further aggravated by low concentrations of
vitamin D in Breast milk.
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Folate deficiency causes megaloblastic anaemia. And in pregnancy neural tube
defects other defects and possibly increased prevalence of pre-eclampsia. Good
sources of folic acid are fruits, leafy green vegetables, and liver. Treatment of
deficiency-folic acid comes in a tablet, usually taken once a day
Women with B12 deficiency have such low levels in milk that babies start manifesting
symptoms that include failure to thrive, stunting, poor neuro-cognitive development or
even global developmental delay. All these delays are irreversible.
Definition:
Severe acute malnutrition is defined as the presence of severe wasting (<70%
weight-for-height or <-3SD) and/or oedema. There is severe wasting of the
shoulders, arms, buttocks and thighs with visible rib outlines. Other features include:
Irritability, misery and apathy, pale sparse hair, skin changes, oedema and poor
appetite.
ASK
Ask mother/caregiver (or check the medical records). Has the child lost weight
during the past month? Does the child have conditions that put them at nutrition risk
like HIV infection, a cough for more than 21 days, active TB on treatment, diarrhoea for
more than 14 days, other chronic OI or malignancy
LOOK and FEEL
Look for signs of severe visible wasting- loss of muscle bulk and sagging skin/ buttocks.
Check for presence of oedema of both feet (and sacrum).
Check the weight and height. Is the weight-for-height less than -3 z-scores? Is the child
very low weight (weight for age less than -3 z-scores)? Is the child underweight
(weight for age less than -2 z-scores)?
Check the MUAC
Table 5: Cut-off points for MUAC for children of different ages
Age MUAC cut off point for MUAC cut off point for
under-weight severe malnutrition
6months-12 months <12.0cms <11.0cms
1 year-5 years <13.0cms <11.0cms
6 year-9years <14.5cms <13.5cms
10years-14years <18.5cms <16.0cms
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CLASSIFY THE NUTRITIONAL STATUS
Table 6: Classification of nutrition status
Acute Severe Poor weight gain Growing well Has conditions
Malnutrition with increased
nutrition needs
Signs of severe Reported weight Child is gaining HIV infection,
visible wasting, or loss, or weight Chronic lung
Oedema present Very low weight disease, or
in both feet, or (weight for age TB, or
Weight-for-height less than -3 z- Persistent
less than scores), or diarrhoea, or
-3 z-scores below Underweight Other chronic OI
median WHO (weight for age or malignancy
reference value, less than -2 z-
or scores), or
MUAC less than:
Confirmed weight
110mm in loss (>5%) since
infants 6mo- the last visit, or
12mo
Growth curve
110mm in
flattening, or
children 1yr-
5yrs MUAC less than:
120mm in
135mm in
infants 6mo-
children 6yrs-
12mo
9yrs
130mm in
160mm in
children 1yr-
children 10yrs-
5yrs
14yrs
145mm in
children 6yrs-
9yrs
185mm in
children 10yrs-
14yrs
TREAT MALNUTRITION
Care givers of children who are growing well should be encouraged on how to continue
to support their children nutritionally.
Children who are growing well but have a chronic illness like HIV require 10% more
energy calories on top of their usual requirements.
Children who are growing poorly or have a condition that increases nutrition
requirements such as TB require 30-40% increase in the energy calories.
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Management of Acute severe Malnutrition (the ‘10 Steps’)
(Adapted from WHO guidelines for treatment of severely malnourished children)
There are ten essential steps for managing acute severe malnutrition
There is an initial stabilization phase where the acute medical conditions are
managed; and a longer rehabilitation phase. Note that treatment procedures are
similar for marasmus and kwashiorkor.
A: STABILIZATION PHASE
The progress is monitored half-hourly for two hours, then hourly for the next 6-12 hours,
recording pulse rate, respiratory rate, urine frequency, stool/vomit frequency. During re-
54
hydration, rapid respiration and pulse rates should slow down and the child should
begin to pass urine. Continuing rapid breathing and pulse during re-hydration suggest
coexisting infection or over-hydration. If these signs occur, stop ReSoMal immediately
and reassess after 1 hour.
To prevent dehydration in a severely malnourished child with continuing watery
diarrhoea:
• If the child is breastfed, continue breastfeeding.
• Continue feeding with starter F-75.
• Give ReSoMal between feeds to replace stool losses. As a guide give 50-100 ml after
each watery stool.
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B: STABILIZATION PHASE
In the stabilization phase a cautious approach is required because of the child’s fragile
physiological state. Feeding should be started as soon as possible after admission and
should be designed to provide just sufficient energy and protein to maintain basic
physiological processes.
For children with a good appetite and no oedema, this schedule can be completed in 2-
3 days. Do not exceed 100 kcal/kg/day in this phase. Closely monitor all the amounts of
feeds offered and left over, vomiting, stool frequency and consistency and daily body
weight
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STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT
In severe malnutrition there is delayed mental and behavioural development.
Provide tender loving care, a cheerful, stimulating environment, structured play therapy
15-30 min/day and physical activity as soon as the child is well enough. The mother or
the primary care-giver should be involved in the care process (e.g. comforting, feeding,
bathing, play)
RTUF can be used as a therapeutic feed, when it provides all the nutrients the child
requires or as supplement for some of the child’s nutrients while the rest is provided by
the home diet. This is most ideal in the recovery phase from malnutrition
Children with chronic disease such as HIV have increased nutrient requirements. At
every point of contact the child should be assessed to determine whether they have:
Severe malnutrition
Gaining weight poorly
Growing well
Having conditions that increase energy requirements such as infection, TB,
HIV infected children who are growing will require 10% additional calories on top of the
normal requirements for their age.
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HIV infected children who are growing poorly or have conditions that increase energy
requirements such as chronic cough, diarrhoea, or TB require 30-40% more calories in
their diet. The table below gives examples of how this can be achieved using a food
based approach. The learner should check with the local Ministry of Health on other
foods that can be used to meet these additional energy requirements.
Table 8: Examples of food portions that can be used to increase energy content of diet
for children of different ages.
HIV infected child who is HIV infected child who is
growing well growing poorly or has
conditions increased
nutrient requirements
Additional nutritional 10% increased energy 30-40% increased energy
requirement on top of requirement requirement
normal requirements
6-11 months 1-2 spoonfuls of fat/oil or 1- 2 tsp oil & 1-2 tsp sugar to
2 spoonfuls sugar added to porridge. Aim to add 3
porridge times daily
12-23 months 1-2 spoonfuls of fat/oil or 1- extra cup of full cream milk
2 spoonfuls sugar added to or cheese/peanut butter
porridge sandwich (1 slice)
2-5years extra cup of full cream milk extra cup of enriched milk
/ fermented milk in addition or cheese/peanut butter
to the normal diet sandwich (4 slices)
6-11year extra cup of full cream milk extra cup of enriched milk
/ fermented milk in addition or cheese/peanut butter
to the normal diet sandwich (6 slices
12-14year extra cup of fruit yoghurt or 3 cheese/peanut butter/egg
cheese/peanut butter sandwiches (6 slices)
sandwich in addition to the
normal diet
If the food items in the table are not available explore with the care giver what can be
used as alternatives.
OBESITY
Obesity is an emerging concept and the prevalence is on the increase all over the
world. It results from an inappropriate high calorie intake with low physical activity.
Management focuses on encouraging well balanced healthy meals and increasing
physical activity.
Interventions for obesity include;
Promoting an active lifestyle and limit television viewing
Limiting high energy-dense nutrient poor foods salty snacks, ice cream fried foods,
cookies and sweetened beverages and emphasize on fruits and vegetables
Set regular meal times, preferably eating as a group to promote social interaction
and role model food-related behaviour.
The lifestyle changes should involve the whole family since it’s a lifelong programme,
needing a lot of support from all concerned bearing in mind a better body image and self
58
esteem being inculcated, cardiovascular diseases and diabetes risks reduced
remarkably.
REFERENCE
1. Black RE, Allen LH, Bhutta Z, Caufield LE, de Onis M, Ezzati M, Mathers C,
Rivera J for the mother and child undernutrition study group. Maternal and Child
Undernutrition 1: Maternal and child undernutrition: global and regional
exposures Lancet 2008; 371:243-60
2. Bhutta Z, Ahmed T, Black RE, et. al. What works? Interventions for maternal
and child under-nutrition and survival. Lancet 2008; 371:417-40.
3. World Health Organization: Pocket book of hospital care for children. Guidelines
for the management of common illnesses with limited resources pg 173-195.
5. www.mypyramid.gov
59
CHAPTER 5
Ruth Nduati
INTRODUCTION
Child growth and development go hand in hand. While growth is a result of increase in
overall size due to increasing number of or enlarging body cells or both, development is
the acquisition of increasingly complex skills for individuals’ adaptation and survival.
Development is a continuous process from conception to adulthood. Indeed the
process of birth is only an event during development. It depends on the maturation of
the nervous system. It is cephalo-caudal in progression and although the sequence is
the same in al normal children, the rate differs. The initial phase of development
involves massive body responses which become specific in later life (for example a six
month old child trying to reach an object with the whole body movement while at the
two years of age the same child simply stretches the arm to reach the object. Due to its
sophisticated and continuous nature, development in a child is amenable to influences
both inherent in the body and external.
It is estimated that more than 200million under 5 children in developing countries do not
achieve their full development potential. In developing country settings there are four
well documented risk factors for poor development: (i) stunting (ii) iodine deficiency (iii)
iron deficiency, and (iv) sub-optimal cognitive and socio-emotional stimulation. In
addition there are four other environmental factors that pose a risk to the development
of the child which include maternal depression, exposure to violence, environmental
contamination, and infections such as malaria and HIV. These factors interfere with a
child’s development and contribute to a trajectory of poor health, lack of readiness for
school, poor academic performance, inadequate preparedness for economic
opportunities and perpetuation of the general cycle of poverty. Primary care can create
an environment that is conclusive to the child’s development. In this chapter, the
student will learn about child development and the factors that influence it.
Objective
At the end of this chapter the learner should be able to;
Outline factors that influence development of the infant and child.
List the developmental domains
Describe the developmental stages of children from birth to age 5 years
Carry out a screening development assessment
Recognize deviations from normal development
Relate developmental to infant feeding practices.
List dangers faced by the child because of stage of development
Outline strategies for promoting child development.
Learning activities
Visit a well child clinic and assess developmental stage of babies aged 1-2 months, 2-6
months and 6months to a year.
60
Visit the paediatric ward and asses the development of a child admitted with severe
malnutrition.
Biological clock
There is a set time when certain skills are achieved, for example children walk at one to
one and a half years all over the world
Genetic endowment
Parental advance age, especially maternal increased age can lead to chromosomal
abnormalities in the conceived foetus. This subsequently causes organ abnormalities
including abnormalities in the central nervous system. A foetus that grows to delivery is
thus ill suited for normal development. Couple counseling, antenatal genetic screening
and therapeutic abortions may be of help in such cases.
Poorly managed maternal diabetes mellitus, hypertension, heart disease, poor nutrition
etc can all lead to poor foetal and later, poor child development.
Some medicines given to the mother early in pregnancy may lead to developmental
abnormalities of the foetus – which become life long. These include radiation (e.g. X-
ray) and cancer drugs.
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Nutritional deficiencies in the mother during pregnancy have negative impact on foetal
development. For example, folic deficiency may lead to abnormal neurodevelopment of
the foetus. Folic acid supplementation is therefore important during pregnancy.
Perinatal Asphyxia
Perinatal injuries and birth asphyxia to the baby remain a significant cause of morbidity
and mortality in children in the developing countries. The brain is particularly vulnerable
and this tends to lead to subsequent abnormal development in the child. Proper labour
monitoring, conduction of delivery and newborn resuscitation can reduce this problem..
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Threshold of responsiveness - how intense should a stimulus be to evoke a response
Intensity of reaction
Quality of mood -usual disposition always happy, always unhappy, always hungry in
class
Attention span and persistence -how long does the child pay attention and stick to a
difficult task
There is value in understanding a child’s temperament and health workers should help
parents understand and accept the characteristics of their children. Behavioral and
emotional problems tend to occur when the temperamental characteristics of the child
and parents conflict. For example, active children maybe a problem for low-key
parents, while slow to warm up children may be pressured by outgoing parents. Parents
who live highly structured lives may fare poorly with children whose biological clocks
occur less regularly.
Social factors
Factors beyond the mother-infant dyad contribute to a higher or lower level of stress
and which impact on the mother-infant relationship. If the mother has an abusive
spouse she may become depressed and is therefore unable to respond appropriately to
the child. Families are complex sub-systems with defined boundaries, subsystems,
roles and rules of interactions. Family with rigidly defined parental systems may deny
children an opportunity to participate in decision-making and thereby exacerbate
rebelliousness. Change in family structure, or individual behaviour results in role
changes until new equilibriums are found for example sick parent who becomes
dependant, or loss of parent. Wider societal issues also influence lives of families.
Increasing urban poverty may radically change the roles of different family members
and in the process adversely affecting child development. The child’s development
ultimately influenced by the interaction of biology and social interactions.
Case study:
Pre-term baby may cry little and sleep long periods of time. A depressed mother
welcomes this as good behaviour setting-up a cycle that leads to poor nutrition, slow
growth and failure to thrive. The child’s failure to thrive may reinforce the parents’
sense of failure. Later impulsivity, inattention and under-nutrition may interact with
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mother’s depression leading to referral for aggressive behaviour. The cause of the
aggression is sum total of prematurity, under-nutrition and mother’s depression.
STAGES OF DEVELOPMENT
Developmental domains
Each of these domains has a line of development or sequences of changes until
maximal skills are achieved.
Gross motor
Fine motor
Social
Emotional
Language
Cognition
Other skills that are important in the older child and which profoundly affecting learning
are the ability to pay attention and to concentrate.
Development;
Has a constant pattern
Begins in utero
Should be considered longitudinally relating what has happened to what lies ahead
Varies in rate between children
There is inter-relatedness in the acquisition of the different skills with deficiencies in one
area affecting development of another area. For example hearing deficits have
profound effect on development of language, as well as socio and behavioral skills.
0-2 months
The first year is a period of rapid physical growth and maturation and acquisition of
numerous competencies. Growth takes place in spurts that qualitatively change the
child’s behaviour
Behavioural goals
In the first 2 months of life the main behavioural goals are to establish;
effective feeding,
a predictive pattern of sleeping and waking and
social interaction that becomes the basis for future social and cognitive development.
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Physical growth and Motor Development
In the 1st week there is a 10% drop in weight which is regained or exceeded by end of
second week. During this period the average weight gain 30g/day. The infant’s
movements in the first 2 months are largely uncontrolled except for the eye gaze, head
turning and sucking. Smiling occurs involuntarily. Babies cry in response to stimuli
such as wet diaper, hunger, and over-heating. Crying peaks at 6 weeks of life with at
least 3hrs/day, and then declines to 1hr/day. Neurological development contributes to
the longer blocks of sleeping time. Learning also contributes to sleeping habits with
babies shifting to night time breastfeeding if the mother is away at work during the day.
Cognitive development
Babies receive visual, tactile, olfactory and auditory stimulus. Infants habituate to the
familiar and pay less and less attention to a stimulus that is presented repeatedly. In
the first 2 months babies can differentiate among similar patterns and colours and
consonants. They respond to facial expressions even when they appear on different
faces. They are also able to match abstract properties of stimuli, for instance they can
tell difference between sound from movement of lips or from a video-tape
Emotional development
The key task in emotional development is to develop basic trust. Key to this goal is
consistent availability of a trusted adult. Babies who are consistently picked and held in
response to distress cry less at one year and have less aggressive behaviour at 2
years. Feeding plays a key role in emotional development. On-demand fed babies link
distress with arrival of mother and relief from distress. Babies fed on fixed schedule
usually adapt. Babies with unstable biologic rhythms and who are fed on a fixed
schedule experience periods of un-relived hunger or unwanted feedings. Similarly
babies fed at parents convenience with complete disregard of baby’s need do not
experience feeding as the favourable reduction of tension. Babies who have a
mismatch between feeding and hunger have increased physiologic instability
manifesting as diarrhoea, spitting, poor weight gain) as well as later behavioural
problems
Success in establishing feeding and sleep cycles increases the parents’ sense of
efficacy independent of child’s temperament. Normally anxiety and ambivalence
experienced by the mother/parents in the first few days after the birth of their baby settle
down as baby develops regular rhythms. Mothers with post-partum depression or blues
may have a harder time making the adjustment and need specific support.
2-6 months
During the period of 2-6 months the voluntary (social) smile and increased eye-to-eye
contact emerges. Parents experience a heightened sense of being loved. At 3-4
months weight gain slows down to 20g/day.
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which then makes intentional rolling possible. Head control allows the baby to gaze
across things and not just up and down. The baby also learns to take food from a
spoon. Maturation of visual system allows much greater depth and field of site.
Sleep requirements are 14-16 hours with 9-10 hours concentrated in the night and up
to 70% of the infants sleep 6-8 hours on a stretch. The sleep cycle is short 50-60
minutes compared to the adult 90 min. in adults and therefore babies wake up
frequently in the night.
Cognitive development
The period of 4-6 months is characterized by increased awareness of the environment.
The baby no longer focused on the mother only but becomes distracted in her arms.
Infant build a sense of self – when he wiggles the toes, he can see and feel the
sensation and do it deliberately. Infants explore their bodies, staring intently at their
fingers, toes, vocalizing, touching the different body parts. The baby learns what is self
and that he has control over it and what is non self which he has no control, for example
smell and touch by mother.
Emotional development
Primary emotions of anger, joy, interest, fear, disgust, and surprise appear in the
appropriate context as distinct facial expressions. Face to face expression matches that
of the trusted adult, for example a mother and baby smiling to each other. If intensity of
stimulation builds the baby turns away. If the mother turns away the baby leans forward
and tries to stimulate mother’s attention. Infants of depressed mothers behave
differently. They spend less time on co-ordinated behaviour and make little effort to
connect and co-ordinate with the parent. The baby shows sadness and loss of energy a
parent continues to be unavailable. Babies’ ability to share the emotional state of their
parents is the first step in development of communication
The 3-6 months period in a child’s life is exciting and interactive. Some parents may
interpret the increasing outward look by the infant as rejection. In the paediatric consult,
the session is happy. If the paediatric visit is not joyful and relaxed, causes of social
stress and family dysfunction, parental illness or problems of infant parent-relationship
should be sought.
6-12 months
Key themes during this period are;
Increased mobility and exploration of the inanimate world,
Advances in cognitive understanding and competences
New tensions around themes of separation
Infant develops will and intention
Motor development
Physical growth slows down. Motor achievements co-respond to increasing myelination
and cerebella growth. Approximately half of the babies are able to sit unsupported by
7months, pivot while sitting by 9-10months, pincer grasp by 9 months, crawling and
pulling to a stand at 8 months and walking at 1 year. The increased ambulation
increases child’s exploratory range, creates new physical dangers and provides new
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learning experiences. Tooth development starts usually with mandibular incisors and to
some extent correspond to skeletal growth.
Cognitive development
Initially everything goes to the mouth. Later novel things are inspected, passed from
hand to hand, banged, dropped, and then mouthed. The pleasure and persistence with
which children pursue these activities points towards intrinsic drive or masterly
motivation. Masterly behaviour occurs when children feel secure and children with less
secure attachments demonstrate limited experimentation behaviour. Object constancy
is a major cognitive milestone achieved at around 9 months. The child now understands
that an object exists even when it cannot be seen. Once this is achieved an infant will
persist in finding objects hidden under a cloth or behind the examiner.
Emotional development
Development of object constancy corresponds to social and communication changes.
Babies begin to differentiate familiar and strange faces and may cling and cry.
Separation becomes more difficult. Babies may wake up more often to check parents
are still there. There is emerging autonomy – infant no longer consents to be fed and
turns away as the spoon approaches or insists on holding it himself. Self-feeding with
finger foods – practice newly acquired fine motor skill (pincer skills) and maybe the only
way to get the child to feed. Tantrums emerge. The drive for autonomy and masterly
conflict with parental control and infants still limited abilities.
Communication
7-month old babies are adept at non-verbal communication showing a range of
emotions and by nine months realizes that emotions can be shared between two
people. As an example, an eight month old baby will show his parents his toys happily.
In a clinic setting, a eight month old baby will start crying because she or he has heard
another baby cry. By eight to nine months, babbling increases in complexity with
multiple syllables (ba-da-ma) and inflection that mimic the native language. This is
followed by emergence of true words - sound used consistently to refer to a specific
subject.
Feeding and sleeping problems re-emerge. Poor weight gain may reflect the struggle
between the infant and the parent over control of the infant’s feeding. Discussions with
parents may help to pre-empt these difficulties. 9-month examination of the child is
difficult because of the babies’ wariness of strangers. Time taken in talking to the
mother and playing with the child will ease these tensions.
12-18 months
Motor development
Further slow down in growth, accompanied by declining appetite. The baby fat burned
up with increased mobility. The child has an exaggerated lumbar lordosis makes the
abdomen protrude. Brain growth continues with myelinization throughout the 2nd year.
Most children walk by one year with highly active fearless infants walking earlier than
the more timid ones. Initially the toddler has a wide base gait, knees bent and arms
flexed at elbow and entire torso rotates with each step. Several months later centre of
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gravity shifts back and torso remains more stable, knees extend and arms swing on the
side. The child is then able to stop, pivot and stoop without toppling over.
Cognitive development
This stage is characterized by accelerated object exploration and the skills of reaching,
grasping and releasing are almost mature. The toddler combines objects in novel ways
to create interesting effects. Toys like stacking blocks are very popular and well liked
by babies in this age group. Playthings are used for intended purpose e.g. combs for
hair, cups for drinking. There is imitation of adult (parents and other siblings) and make
believe play
Emotional development
Before walking the toddler’s predominant mood is irritability. Once they walk they
become intoxicated with their new ability to control the distance between themselves
and their parents. Toddlers orbit round their parents moving away looking back for re-
assurance and then moving further before coming back for re-assurance. In unfamiliar
ground the timid child remains close to the parent while in more familiar surrounding the
baby may orbit out. Ability to use the parent as the secure position for exploration
depends on the degree of attachment relationship. In a strange room, when the parent
leaves most children stop playing, cry and try and follow. When the parent returns, the
secured attached child instantly goes to the parent to be picked and comforted and then
returns to play. Children with ambivalent attachments go to their parents and then resist
being comforted and may hit at their parents in anger. Avoidant children may not
protest when the parent leaves and may turn away when they return. Insecure
response patterns represent strategies that infants develop to cope with punitive or
unresponsive parenting style and may predict long-term emotional problems. Role of
infant temperament in response to separation is still controversial.
Language development
Receptive language precedes expressive language. By 15 months use 4-6 words
spontaneously, and points to different body parts. They enjoy polysyllabic jargoning
and do not mind that others do not understand.
Parents often look forward to the milestone of walking. However the ability to wander
off means there is a need for increased supervision. At this stage children are at
increased risk of injuries. During a health visit an infants who become anxious in their
parents arms and turn to strangers are worrisome and further history and assessment is
required to determine the caring practices. This maybe a sign of neglect or inconsistent
care practices
18-24 months
Motor development
Children develop improved balance and agility. They are now able to run and climb a
staircase. Height and weight increase at a steady rate and head growth slows down.
Cognitive development
Age 18 months marks the end of sensory-motor stage. Object permanence is fully
established and cause and effect are better understood. The toddler begins to
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demonstrate flexibility in problem solving, and for instance may use a stick to reach a
toy that is out of reach. Symbolic play is now not tied to the toddlers’ body, for example
a toy can be fed. Cognitive changes have significant effect on emotional and linguistic
development.
Emotional development
There is increased clinginess as the child becomes more aware of separation.
Separation at bed-time difficult and many children use special blanket or toy as a
transition object, which maybe representing the absent parent. Transition objects
remain until symbolic language develops. Self conscious awareness develops and an
example is when looking at a mirror the child will reach for their own face and not at the
mirror. The child will recognize that toys are broken and may ask parents to fix them.
When tempted to touch a forbidden object they themselves say no- no-no showing that
they are internalizing standards of behaviour.
Linguistic development
Children continue to develop symbolic language. The vocabulary increases from 10-15
words at 18 months to > 100 words at 2 years as children realize that words stand for
things. Once they have 50 words they are able to combine words to make simple
sentences. At 2 years able to follow a two step command e.g. ‘put on your shoes and
then kick the ball’. Emergence of verbal language skills marks the end of the
sensorimotor period. The child learns to use symbols to express ideas and solve
problems and this diminishes the need for cognition based on sensation and motor
manipulation.
Physical limits on child’s exploration become limited with the child’s increased mobility.
For example the child is able to climb out of his cot. There is now increased need for
behaviour control that is based on language. Children with delayed language
acquisition have greater behavioural problems. Language development is facilitated
when parents and other care givers use clear, simple sentences, ask questions and
respond to children’s incomplete sentence and gestures with the correct words.
Regular looking at picture books with a parent provides ideal setting for language
development.
Motor Development
There is reduced somatic and brain growth and therefore reduced food intake and
appetite. During the period 2-5 years children gain 2Kg in body weight and 7cm in
height/year. The child’s prominent abdomen flattens. Physical energy peaks and sleep
requirement declines to 11-13hrs/24 hours. Visual acuity 20/30 at 3 years and 20/20 by
4 years.
All 20 primary teeth erupted by 3 years. Most children walk with a mature gait and run
steadily by 3 years. Acquisition of other skills such as throwing, catching, kicking balls,
riding on bicycle, climbing play-ground structures varies widely. Intensity and
cautiousness during motor activity are influenced by child’s temperament. Energetic co-
ordinated children thrive in an environment that fosters physical competition. Lower
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energy children thrive in environment of quiet play. The child’s handedness established
by 3 years. Development of fine motor skills also related to exposure, for example
children given an opportunity to hold a crayon develop this skill earlier.
Language
Language acquisition depends on environment and intrinsic factors and is a critical
barometer of cognitive and emotional development. Mental retardation maybe first
identified at 2 years from language delay. Child abuse and neglect are correlated with
language delay especially ability to convey the emotional state. Delayed language may
lead to behavioural problems because the child is frustrated by inability to communicate
his ideas and feelings.
Cognition
Children aged 2-5 years have magical thinking and experience confusion about
causality
- it rains because people carry umbrellas.
- the sun goes down because it is tired and therefore goes to sleep.
Play helps children develop masterly over their fears. Children who are abused will
often play the role of an aggressor. Drawing and other artistic expression are also play.
The games often point towards the experiences the child is undergoing and provide a
powerful way of communicating with a child. Play and drawing activities are increasingly
being used in clinical settings to communicate with young children.
Emotions
The child aged 2-5 years has the challenges of reigning in their emotions. Children will
have intense feeling for their parents. They use internal images of trusted adults to
provide security during times of stress. At the same time children learn what is
acceptable by testing the limits. Tantrums occur occasionally. Tantrums that last more
than 15 min duration and more than 3 times a day reflect underlying heath, social or
emotional problems. They are also curious about genital organs but become intensely
private from 4-6 years.
The physical developmental characteristics have implications for parents and health
care workers. Parents worry about the reduced appetite. Motor precocious children at
increased risk of accidents and this is the peak age of non-intentional injuries and
poisoning. Parents concerned about hyperactivity may be having inappropriate
expectations of their children. Truly reckless children involved in activities without
consideration of their safety need protection. Hyperactivity maybe associated with child
abuse and neglect. Conservative parents maybe worried that their child is
masturbating.
DEVELOPMENTAL ASSESSMENT
Child development assessment should be carried out at every contact with the child.
This assessment provides an opportunity to discuss with the care-giver difficulties they
may be experiencing and strategies for promoting the child’s development. There are 4
fields of developmental skills that need to be considered when assessing the
development of a young child.
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Gross motor
Vision and fine motor
Hearing, speech and language
Socio-emotional and behavioural
Cognitive development is assessed on its own in the older child.
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Median age of acquiring a milestone is the age at which half of the children acquire the
skills, while the limit ages are usually 2 standard deviation above the median. The limit
ages for different development milestones are shown on table 1. These ages are a
guide to when the child’s development is normal and when an assessment is required to
determine the cause of delay in development. Adjustment for gestational age should
be made in the first two years of life during developmental assessment.
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been achieve in Africa. Health workers need to constantly encourage the public to use
iodinated salt.
Iron deficiency anaemia impedes child development and the detrimental effect in
toddlers and infants is not readily reversed with supplements. Supplementation of
deficient children has shown positive effect on motor, socio-emotional and language
development.
Some of the strategies for improving iron security include use of micro-capsulated iron
with vitamin C, growing of iron rich foods, and removing phytates from plants at the
point of food production in order to reduce inhibition of iron absorption. Iron
supplementation of replete children has been shown to be associated with slowing
down of linear growth and increased hospitalization and death in endemic areas.
Social risks
These include maternal depression, exposure to domestic and community violence and
stigma and loss associated with HIV/AIDS. Studies suggest that women in developing
countries experience high levels of stress and depressive symptoms often associated
with poverty, lack of support and negative life events. Children of depressed mothers
are at risk because of inconsistent or unresponsive parenting. A Jamaican study has
shown that participation in parenting classes was associated with reduced levels of
stress, however the latter was not associated with improved cognitive functioning of
their children. Violence is often as a result of excessive corporal punishment, child
abuse or neglect. To date there is limited data on whether programs providing ‘social
protection’ to children mitigate against the adverse effects on development.
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Environmental risks
Exposure to heavy metals such as lead and arsenic leads to irreversible brain damage.
Chelation of lead in exposed children reduces the plasma and bone content but has no
effect at all on development. The global shift away from leaded petrol has significantly
reduced the number of children exposed to lead. Arsenic is usually dissolved in water
from shallow wells. One intervention is to sink deep wells.
Infections
Control of infections – malaria and HIV/AIDS will reduce number of children at risk of
poor development. Cerebral malaria is associated with long-term neuro-cognitive
effects. The interventions are described in the respective chapters in this manual.
Communities and governments are not aware of the children’s loss of developmental
potential, the potential cost of this loss on individual children and on poverty alleviation.
The lack of agreed on global indicators for measuring child development at population
level makes it difficult to monitor the interventions. Governments are faced with many
acute needs and therefore find it difficult to invest on long-term development. There are
also multiple groups interested in the young child resulting in a situation where no one
group takes responsibility. There is also the added challenge that there is no single
strategy for promoting child development.
Health workers need to advocate and promote early childhood development programs
with the understanding that events in early childhood affect learning and productivity
throughout life. Interventions in early childhood are cost effective improving efficiency
and effectiveness of education programs, in one intervention. Increased schooling for
girls has long term e3ffect on child survival and development. Early childhood
development programs are sustainable in that hey lead to development of new
standards and norms of rearing children.
Conclusions
Normal early childhood development is the foundation for a healthy life in the future. At
every contact the child’s development status should be assessed. Communities and
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governments are not aware of the children’s loss of developmental potential, the
potential cost of this loss on individual children and on poverty alleviation. Health
interaction with the mother and communities is an opportunity to improve community
awareness of the importance of child development.
BIBLIOGRAPHY
Engle P, Black M, Behrman JR, Cabral de Mello M, Gertler PJ, et al. Child development
in developing countries Strategies to avoid the loss of developmental potential in more
than 200 million children in developing countries. Lancet 2007;369:229-242.
Normal Child Development, hearing and vision. In: Lissauer T and Clayden G
Illustrated Textbook of Paediatrics 3rd Edition.
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CHAPTER 6
INTRODUCTION
Growth is the gradual increase of the body size and shape and it consists of increase in
cell numbers and their size. The period from conception to age of 2 years is the fastest
growing period in life and is thus much more vulnerable. It is important to ensure
adequate growth during this period as insults occurring during this period are
irreversible. Growth depends upon adequate nutrition, appropriate physical and social
environment, as well as normal health. Up to the age of five years children around the
world have the same growth pattern if their health and nutritional needs are met. The
growth of a child, visibly displayed on an appropriate chart, is the most important
sensitive tool of measuring his health and nutritional status. When growth is charted
regularly over a period of time in infancy and early childhood, it is known as growth
monitoring. It is often done together with growth promotion as a combined operational
child survival strategy in Primary Health Care (PHC). It provides evidence of a child
who is growing well and helps to identify the child who is not growing well. When a child
is not growing well, appropriate health interventions such as treatment of illness and
provision of nutrition are carried out to promote good health and nutrition.
OBJECTIVES
At the end of the chapter the student should be able to:
Define growth
State the role of individual’s genetic constitution on growth and development
State other factors, besides the genetic constitution, which influence growth and
development
Explain the concept and strategy of growth monitoring and promotion as a means of
measuring and promoting health and nutrition of a child.
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Understand the inter-dependency and the differences between growth monitoring and
promotion and nutritional assessment.
State the importance of growth monitoring in the under fives.
List four main objectives of growth monitoring through weight/age charts.
State the steps necessary for growth Monitoring and Promotion.
Measure the growth accurately, plot the measurements carefully on the growth chart
and correctly interpret the child’s growth pattern.
Report the measurements to the mother and inform her how her child is growing.
Counsel the mother
List the seven tasks of identifying growth monitoring needs in the community.
Recognize the role on integrating health education and operational research into
Growth Monitoring Programme.
LEARNING ACTIVITY
It is assumed that the student will visit the child welfare clinic and learn from the nurse
or doctor how to weigh babies accurately. Find out the kind of scale used. Plot the
weight of one or two children on the child health card. Find out whether the majority of
children are well nourished or not.
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INDICATORS OF GROWTH
The following measurements are used as indicators of growth. Weight-for-age, height-
for-age, weight-for-height, head circumference and mid-upper arm circumference.
As a general rule, birth weight doubles by 5-6 months, and triples at 12 months. As the
age increases the rate of growth gradually slows down.
Circumferences
Mid-upper-arm-circumference (MUAC)
MUAC not routinely used as growth monitoring tool but is very useful in assessing
nutritional status of infants and young children. Specific tapes have been designed with
different colour bands that help in screening for malnutrition in communities with limited
resources and who have minimally educated health workers.
Age MUAC cut off point for MUAC cut off point for
under-weight (< than severe malnutrition (< than
reference value) reference value)
6months-12 months 12.0cms 11.0cms
1 year-5 years 13.0cms 11.0cms
6 year-9years 14.5cms 13.5cms
10years-14years 18.5cms 16.0cms
Head circumference
This is a good measure of brain growth especially in the first 2 years of life. While not
strictly part of normal growth monitoring and promotion strategy, head circumference
measurement is of great value in follow-up of low birth weight infants, and in children
with abnormalities of the central nervous system, e.g. suspected post meningitic
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hydrocephalus. Head circumference charts exist but are not included in country child
growth monitoring cards. The normal head circumference at birth is 34-36cms. The
head circumference increases 2cm/month for the first 3 months, the 1 cm/month in the
period 3-6months. In the period 6-12 months the head circumference increases
0.5cm/month. Overall the head increases by 10cms in the first year of life. The head
circumference is a sensitive way of identify children at risk of mental retardation
because of poor brain growth (microcephaly) or too large a head with hydrocephalous.
Waist circumferences and waist/hip circumference ratios are currently used to monitor
obesity in adults. Standard measurements for children have not been developed.
DEFINITIONS
Growth monitoring is the regular and sequential weighing of the child, recording the
measurements on a growth chart. In doing so the growth can be easily visible and
demonstrated or explained to the mother. Growth promotion, on the other hand, is
giving the mother of such a child relevant and practical guidance within her means or
that of the family or the community on what to do to ensure growth continues well or
resumes, in case where it was not proceeding normally.
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Performance of Growth Monitoring
Having grasped the concept of growth monitoring and promotion, the student should
learn to perform accurately the task of growth monitoring and promotion. Medical
officers require this skill in order to fulfill their roles as health workers and supervisors of
other health workers at health facilities and in the community. The following sub-tasks
or steps are important in performing growth monitoring and promotion.
It is recommended that the student finds out the most commonly used weighing scale in
his country, as types vary from one country to another. Students should be able to
describe the major parts of the scale. An example of a scale is the Salter Scale which is
widely used in community growth monitoring. This will be used to illustrate measuring
the weight for infants and children.
Each scale is usually supplied with four sets of strong plastic pants but other cotton
pants or a basket will do. Before weighing a child, the weighing scale is checked for
proper working. The checking is done through weighing a known weight and noting
whether that is the weight obtained from the scale. The scale is hung securely from a
roof beam or a tree with the dial of the scale at heath workers’ eye level for correct
reading.
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Figure 1: Growth monitoring using a hanging scale
Let the mother prepare the infant for weighing by removing heavy clothes and shoes,
including the nappies.
After explaining to her that the baby is going to be weighed, the mother is asked to
dress the child with the weighing pants as shown in figure 1 above. The loops of the
pants are put over the lower hook of the scale. If old enough to understand, the child is
asked to hold on to the straps of the pants while the mother stands nearby, talking and
calming but not holding the child. The child’s feet should be off the ground as shown in
the picture in Fig. 1. A struggling child is calmed with the help of the mother.
When the child stops moving, the weight is quickly read to the nearest 10 gm in infants
and 100 gm in children. Help the mother to remove the child/infant from the sling
carefully
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Take the measurement without compressing the head. Take the reading at which the
tape crosses the zero mark. Ensure that the tape is on the same plane.
The piece of string used in the absence of a tape measure is then measured with a ruler
to obtain the head circumference
Used in settings with limited resources, the mid upper arm circumference is measured
using a tape or string in the absence of a tape. MUAC is taken on the left arm using a
non-stretchable tape. Follow the 6 steps in measuring MUAC.
Ask the mother to put the child on her lap or carry it in her arms.
Request the mother to support the left arm of the child in a bent position.
Identify by palpation the outer part of the acromion (prominent bone of the shoulder)
and the outer part of the olecranon (prominent bone of the elbow).
Using the tape, locate the middle of this segment and mark it off using a pen, on the
back of the arm: this is the mid upper arm.
Let the arm of the child rest loosely on the body (may be held). Put the tape around
the arm and take the mid upper arm circumference at this place, without
compressing the arm. The tape should be perpendicular to the axis of the arm. The
result is the value at which the tape is crosses the zero mark. Make the reading to
the nearest millimetre.
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Repeat the measurement and take the mean. If the two readings differ by more
than 5 millimetres, take a third measurement and keep the 2 closest readings).
The string used in the absence of a tape measures is then measured with a ruler to
obtain the mid upper arm circumference. If available colour coded tapes are extremely
useful and can be used by people who have relatively limited training.
See Fig 3: Drawing showing the measurement of mid upper arm circumference
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Straighten the child on the table along the measuring rod and support the trunk of
the child while the assistant holds the child’s head with the hands and slowly puts it
on the fixed head bar of the rod as shown in figure 5.
Ask the mother to stand near the child to help him/her stay calm.
Hold the child’s head on the fixed part of the rod. The axis of the child’s eyes must
be perpendicular to the ground. Ensure that the child is straightened flat on the
table: shoulders and hips should be aligned, perpendicular to the axis of the body
and of the rod.
Put your left hand on the knees of the child and apply them firmly on the table. With
the right hand, apply firmly the sliding part of the device on his/her heels (the child
should not push the sliding part with her/his toes or heels). Check the position of
the child. Repeat the procedure if necessary. State the reading by separating the
decimal to the nearest millimetre (example: ‘45 centimetres and 3 millimetres’).
An assistant or the mother should hold the child to allow the operator record the
reading to the nearest millimetre.
Operator and Assistant: Repeat the procedure in the same way from point 2 and
record the second reading. If the two readings differ by more than 5 millimetres,
take a third measurement (keep the 2 closest readings).
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Fig 5: Measurement of length in a young child aged < 2 years
Plotting Weight,
Height Information
on Child Health
Card
A baby should be
issued with a child
health card/booklet on first contact with health services. Besides growth monitoring, the
card incorporates important information about the child, mother, and family and it
enables the health worker to have access to the information at every contact with the
child without embarrassing the mother by asking the same information at each visit.
Information included will vary according to the country issuing it but the growth charts
are going to be identical. The reading of weight obtained must be plotted on growth
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chart which is found on the Child Health Card. The growth chart is the second tool used
in growth monitoring and promotion. The student should familiarize himself with the
child health card used in his own country. One needs to understand the child health
card first.
The graph on which the child's weight can be plotted against age is on the inside of
folded Child Health Card.
These were launched in 2006 and many countries have adapted or are in the process of
adapting them to replace the older variety. They are truly international and are based on
the growth curves of breastfed infants. They establish breastfeeding as the norm for
early childhood feeding. The student should check in their respective countries how far
the adaptation process is. It may take a bit of time before the older ones are completely
phased out.
Note: the older charts which were being used in the region had only two lines. The
lower line represented the 3rd percentile weight for age for girls, and the upper one 50th
percentile for boys. The new charts separate boys and girls, and include weight for age,
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height for age. The generic charts have a middle line representing the 50th percentile,
+1SD and -1SD representing one standard deviation above and below the mean, +2SD
and -2SD representing two standard deviation above and below the mean, +3SD and -
3SD representing three standard deviation above and below the mean. The SD lines
are also called Z-scores. Growth chart lines are the Z-score – upper most is the +3 Z-
score while the lower most is -3 Z-score. Others may include + or -2, and + or -1 Z-
score according to decisions of different countries. Normally 97% of normal children fall
with the bounds of the + 2 SD. Children growing at > 2SD are moderately underweight
or over weight while those that are at > 3SDare severely malnourished (over-weight or
under-weight). Any child falling outside of these needs intervention. But as pointed out
below the most important thing is that the child follows his/her line of growth.
Fig 7: How to Plot the Weight on Growth Chart
The birth weight is plotted in the middle of the month of birth which is written in the first
heavily marked box below which the year of birth is written as shown in chart A above.
The successive months of each year are then filled. If the child initiates growth
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monitoring later and the birth weight is not known the first weighted is plotted in the box
that corresponds to the age of the child as shown in chart B. Chart C shows how to
locate the point to mark the weight of the child. The successive weights are connected
with a line on the growth chart as shown in chart D to produce an individual child’s
growth curve or pattern. This plotting of the weights on the growth chart is indispensable
in growth monitoring. Un-plotted, the individual weights indicate the sizes without
indicating whether the infant or child is growing well or not. You need to study a blank
growth chart to be thoroughly familiar with its contents see. When the growth curve is
plotted, the health worker and the mother can see at a glance whether the child is
gaining weight appropriately by watching the direction of the child’s pattern. The
direction is more important than the position of the curve on the child health chart.
The direction of the growth curve is more important than the position of the curve on the
chart. The weight growth pattern of the larger term infants will be above the pattern of
the average term infant. On the other hand, the weight growth pattern of the smaller
term infants will be below the pattern of the average term infant. A small baby whose
growth pattern is below the bottom line in the growth chart is healthy if that child’s
growth pattern is parallel to the bottom percentile line. As long as the baby is gaining
weight at an acceptable rate indicated by the baby’s growth curve being parallel to the
printed curves, the mother should not worry about the position of her child’s growth
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curve on the child health card. Figure 9 below is an illustration of a child who is growing
well.
LEARNING ACTIVITY
To illustrate this we shall use the example of an infant called Wambui, born in
February 2008, whose birth weight was 3kgs, who attended a growth
monitoring session for the first time in July 2008, when his weight was 6.0kg.
He was seen again in September of the same year and he weighed 7.5kgs.
Write the name and birth weight in the right hand corner of the card. Print the
year 1994 at the beginning below the first box of the first year, and then
subsequent years. Print February in the first box of the first year, then fill the
subsequent months for each year. Place a dot in the middle of the column as
illustrated in figure 2, for the birth weight (middle of February) and the second dot
in the middle of July, September boxes, at the respective weights. Join all the
subsequent recordings (dots) with a straight line. Using this information, plot
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Wambui’s growth on a growth chart on the blank child health card below. Is
Wambui’s growth adequate? Why do you say so?
Wambui’s growth curve is constantly going upwards. A constantly upward going curve
parallel to the printed lines shows GOOD growth. The mother, the person most
responsible for the child’s good health, is informed how her child is growing and praised
for her good efforts.
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A horizontal (flat) growth curve like the one in Fig. 11: horizontal growth curve. A
horizontal growth curve indicates DANGER! The horizontal growth curve means the
child is not growing, a sign of disease, especially malnutrition. A child who is
malnourished cannot grow properly, cannot resist diseases, and is in danger of getting
killer diseases. You should take a thorough history from the mother to establish the
cause of growth failure and then give the mother the relevant and practical guidance
within her means or the means of the family or of the community on what to do to
ensure continuation of normal growth or resumption of normal growth in case where
there was growth faltering manifested by horizontal or downward deviation of the growth
curve. The mother is encouraged to give the child food containing enough calories,
protein, vitamins and minerals. Thereafter, growth monitoring helps to determine the
adequacy or inadequacy of catch-up growth.
Catch-up growth
Successful nutritional rehabilitation is associated with a growth spurt. During the growth
spurt there is a very steep increase in weight. The weight finally levels off at the
appropriate weight for height. The weight of HIV infected children may level off at low
weight for height. Increased caloric intake results in increased adipose tissue rather
than lean body mass.
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In the real world, children may experience different types of growth patterns over the
period of early childhood. Fig.13 Another horizontal curve is an illustration of another
child’s growth curve. The child was growing well until about 5 months of age. From this
point, the growth curve started being flat. The horizontal deviation indicates static
growth. This is not good and action should have been taken by the health worker and
the parents of the child earlier.
Depending on the individual’s growth pattern, an infant at the 5th percentile of weight
for age may be growing normally, may be failing to grow, or may be recovering from
growth failure. In chart 13 the child was growing on the -3 line in the first 5 months but
gaining weight well. From the 5th month, the child ‘s weight gain slowed down and
eventually became static. As illustrated at the bottom right hand corner of the growth
chart, important events that affect the child’s growth should be recorded above the
weight on the Growth Chart. Such events include diseases, weaning, introduction of
solids and stopping of breastfeeding.
Reasons for special care: At the bottom of the Growth Chart there is a box that lists
some of the factors that may make a child particularly vulnerable to malnutrition. These
factors include low birth weight, twins, large family, child spacing of less than 2 years,
and history of sibling death. A tick or mark should be made next to any of the reasons
that apply. This will then remind you to be particularly alert to any signs of growth
faltering and may suggest the reasons for poor growth. You can then plan how best to
help this particular child.
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There are also weight for height charts and tables. Weight for height below the fifth
percentile is a good indicator of acute undernutrition. Measuring weight for length/height.
Weight for length/height is also used for monitoring growth. A child with acute severe
wasting has weight for length/ height Z score of -3. Such a child should be admitted for
treatment of malnutrition.
Growth monitoring will help you to detect growth failure early so that severe malnutrition
can be prevented. Growth monitoring should be continued up to the age of 5 years as a
component of well child care. Encourage parents to have their children weighed. The
health worker should avoid keeping the mothers waiting for too long and should have
the children undressed very shortly before their being weighed. You must always report
the findings to the mother or caretaker, inform her how the child is growing and counsel
her..
Counseling of mothers can also be done in a small group. Such a group allows more
sharing of ideas and advice among the mothers themselves. The health worker
facilitates the discussion, listens to the mothers very attentively, and provides the
necessary information that the mothers can use to promote the health of their children.
The success of a mother whose children are growing well become the best source of
information for the advice to other mothers. Always remember that mothers are
concerned about the health and welfare of their children and they will do anything to
make their children grow well.
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When Should Growth Monitoring and Promotion Start
In order to detect growth failure, growth monitoring should start as early as possible,
soon after birth, effective growth promotion focuses on the youngest ages and attempts
are made early to foster participatory action by mothers. There are two major
advantages of starting growth monitoring/promotion early:
Growth failure can be detected early for it to be corrected before the child becomes
malnourished
Growth promotion is easier to initiate in early infancy when positive growth can be used
as positive reinforcement. During early infancy mothers have more control over the
environment of their children, are prepared to devote more time and efforts to the health
of their children and can be effectively used as agents of change.
How Often and for how long should the Child be Seen for Growth Monitoring and
Promotion
The frequency of growth monitoring is determined by the velocity of growth and the
additional services that the child is being provided with such as immunizations. During
the first year of life there is rapid growth and development. The child makes a major
transition from intrauterine life to postnatal life and from being totally dependent on
breast milk to consuming an adult diet. These rapid changes make a child vulnerable to
malnutrition. Careful and frequent monitoring of growth enables prompt interventions.
The child should be monitored monthly in the first 24 months of life, 2-3 monthly in the
third year of life and then twice a year thereafter.
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CONCLUSION
The present chapter has outlined the role of growth monitoring and promotion in
promoting child health within PHC setting. GMP a low cost effective strategy is used to
visualize growth of young children to their mothers and health workers. Growth
monitoring also provides a tool for evaluating other interventions for promoting child
health. It provides education and communication stools for appropriate action to be
taken at the household level to support normal growth of children. Nutrition and health
information obtained as part of GMP should be used for re-assessment and modification
of ongoing child health intervention.
Discuss the major difference between nutritional assessment and growth monitoring
and promotion.
Compare and contrast a growth monitoring session at a health centre and at a village
outreach session. Point out the advantages and disadvantages of holding session at
each site.
Outline the role of health education in the promotion of growth monitoring in the
community.
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BIBLIOGRAPHY
De Onis M, Garza C, Victora CG et al. The WHO multicenter growth reference study
(MGRS): Rationale, planning, and implementation. Food and Nutrition Bulletin 25 No 1
(supplement 1) March 2004
De Onis M, Garza C, Onyango AW, Martorell R. WHO Child Growth Standards. Acta
Paediatrica Vol 95 (supplement 450) April 2006
Genece E., and Rhode J.E.: Growth Monitoring as entry point for Primary Health Care
Indian Journal of Paediatrics (Suppl.) 1988. 55.S 78 - 83.
King MH Nutrition for developing countries. A Weight for Age Graph Showing Growth
page 1.3 fig 1.7
Lalitha, N.V. and Standley: Training workers and supervisors in growth monitoring
Indian Journal Paediatrics (Suppl.) 1988 55, 548.
Morley D, and Woodland M. See them grow. McMillan Tropical Community Health
Manual. McMillan Press, 1979.
Rohde, J.E.: Beyond Survival; Promoting Health Growth, Indian Journal Paediatrics
(Suppl.) 1988 55 - 85.
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CHAPTER 7
CHILDHOOD IMMUNIZATION
INTRODUCTION
Immunization as an element of primary health care is one of the most powerful and
cost-effective means of preventing infectious diseases but remains tragically
underutilized in many African countries. Percentage of one year old children who are up
to date with their immunization has risen from 20% in 1980 to about 80% in 2006.
However this still falls of the 90% target for developing countries Over the last few
years, Polio has been controlled in most African countries with only a few reporting
cases of wild polio virus. Measles mortality has reduced greatly, all of these following
mass immunization national immunization days. Pentavalent vaccine containing
Haemophilus Influenza type-B and Hepatitis B in addition to DPT has been introduced
in the region for the last 6 to 8 years. This has substantially reduced the mortality from
Haemophilus influenza type-B (meningitis and pneumonia). There is an ongoing
disease surveillance of vaccine preventable diseases that is also going to provide
information to help in the introduction of new vaccines in the region e.g. pneumococcal
and rota-virus vaccines.
OBJECTIVES
At the end of this chapter the student should be able to:
LEARNING ACTIVITIES
Observe health workers in a health care facility administering vaccines. Note the various
steps from the time the parents enter the facility to the time they leave. Evaluate the
health team performance.
Participate in administration of vaccine in the same facility under supervision of qualified
health worker
Note how the immunization programme in the facility is organized and what problems
the health workers encounter in performing their task
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Interview five parents attending the facility picked at random and ask them when they
last brought their children for immunization and determine this was according to EPI
immunization schedule.
The expanded programme of immunization focus on eight diseases. Measles affects all
un-immunized children, kills over 2.0 million children annually. Pertussis kills about
600,000 children each year and causes severe complications in many others.
Neonatal tetanus is contracted through contamination of umbilical cord. It kills about
800,000 neonates per year. Tuberculosis attached each year about 10,000,000
children and can be very severe in young children. Polio has been the major cause of
lameness in developing world until recently. Diphtheria is now less common but kills
about 10 to 15% of its victims. Haemophilus influenza type-B has been one of the major
causes of bacterial meningitis and pneumonia in children until recently after introduction
of an effective vaccine.
Hepatitis-B does not manifest early in childhood, but children get infected as they grow
up and subsequently the disease may lead liver cirrhosis and cancer of the liver.
The challenges facing the immunization programme is to deliver basic vaccines to all
susceptible infants and tetanus toxoid to women of reproductive age.
IMMUNIZATION SCHEDULES
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World Health recommended schedule is as follows:
AGE Vaccine
BCG and OPV
At Birth
At 9 months Measles
Key:
HepB B Hepatitis B Vaccine
Hib Haemophilus Influenza type-b
BCG Bacille Calmette Guerin
OPV Oral Polio Vaccine
DPT Diphtheria, Pertussis and Tetanus
It is recommended to give four does of Oral Polio in the first year of life. The first OPV
(OPVo) is given at birth or within the first two weeks after birth. The other three OPV
doses are given four weeks apart along with other vaccines as above. Extra doses of
OPV may be given at school age just after five years and at entry to secondary or
during national immunization days.
Interrupted immunization need not be started afresh. The remaining doses should be
given as if the prolonged interval has not occurred. Children who have their first contact
with EPI services after 6 weeks of age and less than 9 months should receive BCG, DT
and OPV first and continue OPV and DPT at four weeks intervals as above. An infant
encountered after two weeks of age forfeits OPVo and will have to wait for OPV one.
Five doses of Tetanus Toxoid (TT) to the mother will give longer immunity to the mother
and she will be able to pass adequate immunity to her offspring, preventing neonatal
tetanus.
The schedule for TT in women of reproductive ages
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For pregnant mothers two doses may be given in first pregnancy at four weekly
intervals starting as early as possible. The rest of the TT doses may be given in the
subsequent pregnancies
Ensure that boiling water cover all the equipment and boil for at least 20 minutes
Ensure that sterilizer lead is properly in place during boiling.
For steam sterilizer read the manufacturer’s instructions and following them strictly
Use one sterile needle and syringe per injection per child
1. BCG is given intradermally into the deltoid area of the right upper arm
Since BCG dose varies with age and manufacturer careful read the manufacturer’s
instructions.
2. For OPV give two drops orally only
3. For DPT vaccine 0.5 mls. is given intramuscularly in the anterior mid thigh in the
quadriceps muscle.
4. Measles vaccine is given 0.5 mls IM in the deltoid muscle
5. Tetanus Toxoid for pregnant mothers is given I.M 0.5 mls in the left deltoid muscle.
Remember to tell the mother about the side effect of each type of vaccine given to the
child and advise her on what to do should they happen.
RECORD KEEPING
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COLD CHAIN MANAGEMENT
The cold chain is a system that ensures that the vaccines are kept between 0 and 8
degrees centigrade between transportation from the manufacturer to the people to be
vaccinated. The cold chain is necessary because the vaccine lose their potency when
exposed to higher temperatures. Successive exposures have cumulative impact on
vaccine potency. Once lost, potency cannot be restored. A typical cold chain consists of
four levels:
National
Regional or provincial
Health centre of hospital
Local health post or other location where vaccinations are carried out
IMMUNIZATION PROBLEMS
Lack of resources which include staff, supplies and equipment is the major constraint in
the delivery of effective immunization services in developing countries. In a tropical
environment with unreliable electricity supplies and lack of vehicles to carry vaccines
the cold chain is highly vulnerable to interruption with consequent loss of vaccine
potency.
Although no vaccine is total without adverse reaction, the risk of serious complications
of vaccines used in EPI is much lower than the risks of natural diseases. Important
reasons for the less than optimal immunization coverage include: postponement of
immunization of children, who are ill, who have upper respiratory tract infection, who
have fever, diarrhoeal diseases or who are malnourished. Yet these are the very
children who most need immunization.
An infant between 6 and 9 months of age seen in the health unit may be vaccinated
against measles when:
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Such children vaccinated against measles before 9 months of age will have to be
revaccinated at one year.
Common side effects of vaccines are mild and severe ones are very rare:
Low grade fever with skin rash may occur for 4 – 7 days after measles vaccination
Reactions to oral polio vaccine, including paralysis similar to poliomyelitis, diarrhea,
perhaps one in every million doses
BCG vaccination will cause a small sore at the vaccine site. The sore usually
disappears after one or two months. Rarely this sore will become a chronic ulcer
BCG adenitis with abscess formation may occur
Most common side effects is local infection an abscess formation at the injection site
because of needle and syringe contamination
Infants with clinical AIDS should not receive live vaccines e.g. BCG or OPV, but should
be given the other vaccines.
EFFICACY OF VACCINES
Vaccines differ in their efficacy that is the ability to produce immunity in a susceptible
population vaccinated under optimal conditions. The table below shows efficacy of
various EPI vaccines.
Measles >95%
Polio >95%
Diphtheria >95%
Pertussis >60%
Tetanus >95%
BCG Variable
HepB-B ??
HiB ??
HEALTH EDUCATION
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EDUCATION AND SUPERVISION OF HEALTH WORKERS
To ensure that all children needing immunization are properly vaccinated with potent
vaccines field workers must learn to:
A good system is essential to a successful programme and people always work more
carefully when they know that their performance is being evaluated. The essentials of
good supervision are:
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at the antenatal clinics, under five clinics, outpatient clinic, inpatient wards, women’s
clubs, schools, and child to child programme.
EVALUATION
Evaluation assesses performance at all levels based on predetermined objectives. The
main areas to evaluate progress in an immunization programme relate to:
access to vaccination, e.g. OPVo coverage
immunization delivery processes
vaccination coverage
disease incidence or prevalence
SURVEILLANCE
The main objective of surveillance for vaccine preventable diseases is to inform the
programme on different aspects of the diseases under surveillance. The vaccine
preventable diseases currently under surveillance in different countries of the region
include: Polio, Measles, HiB, Neisseria meningitidis and strep pneumonia. The
essential elements of a surveillance system are:
Disease recognition;
Disease reporting
Number of cases
Number of deaths
Characteristics of cases
Location and dates of out-breaks
Immunization status by vaccine, dose and age groups
Feed back and utilization of results.
There are two measurement systems used in immunization coverage, one based on
service statistics and the other on sample surveys.
NEW DEVELOPMENTS
New biotechnology including recombinant DNA, monoclonal antibody and protein
synthesis continues to spur vaccine research. The diseases where such research is
currently underway include: Malaria, Rota virus, AIDS, Respiratory syncytial Virus
(RSV).
New vaccines against cholera and typhoid fever are being developed to replace the
current ones which are being used.
Rota and Human Papiloma virus vaccines have been developed and their field efficacy
studies are in progress
SAFETY OF INJECTIONS
Disposable syringes and needles used for giving injections for treatment and
immunization should be safely disposed of. They should be put in special containers
and taken for incineration. Small portable incinerators are now available in small health
centres. Disposable needles and syringes should never be thrown away into a garbage
pit from there can be collected for re-use, or pose a danger to children.
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CHAPTER 8
Israel Kalyesubula
INTRODUCTION
It is one of the leading causes of illness and death among children in developing
countries. It is estimated that 1.3 thousand million episodes of diarrhoea and 3.2 million
deaths from diarrhoea occur annually among children under five years in the developing
countries. Overall, children experience an average of 3.3 episodes of diarrhoea per
year. In some areas, the average exceeds nine episodes per year.
Diarrhoea contributes about 25-30 per cent of the total deaths in the under fives. About
80 per cent of deaths occur in the first two years of life. The main cause of death from
acute diarrhoea is dehydration, which results from the loss of fluid and electrolyte in the
diarrhoeal stools. Other contributory factors include: preexisting malnutrition serious
undercurrent infections such as pneumonia and delay in seeking care in cultures that
believe that the diarrhoea is due to “false” teeth that would need to be extracted.
Correct case management of diarrhoea both at home and at health facilities saves
many lives. This includes the use of hypo-osmolar oral rehydration salt (ORS) solutions
combined with zinc supplements. Antibiotics are used in selected types of diarrhoea.
OBJECTIVES
At the end of this chapter the student should be able to:
Define diarrhoea
Outline the difference between acute and persistent diarrhoea
Describe the role of diarrhoea on the burden of illness in children in the developing
countries
List the risk factors for diarrhoea morbidity and mortality in children
List the viral, bacterial and parasitic causes of diarrhoea
Describe the pathophysiology of diarrhoea
Describe the complications of diarrhoea and explain how diarrhoea causes dehydration
and malnutrition
Describe dysentery and persistent diarrhoea
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Describe the standard case management of diarrhoea: assess, classify dehydration and
manage diarrhoea
(10) Describe traditional methods of treating diarrhoea and their complications
LEARNING EXPERIENCE
Practice proper history taking in a child with diarrhoea, with emphasis on detecting the
severity of dehydration
Observe and participate in assessing the degree of dehydration
Calculate the amount of fluids required by a child with some dehydration and assist the
mother in giving ORS to her child
Demonstrate to the mother how to prepare ORS
Advise the mother on how to manage and prevent diarrhoea at home
Using the case illustration given below, the student to perform role play, with one
student acting the health worker role while the other acting the mother role
Review epidemiology, aetiology and pathophysiology of watery diarrhoea
Review the diarrhoea case management video
CASE ILLUSTRATION 1
Monde, a 12 months female from Kalingalinga shanty compound is brought to a local
hospital with a two day history of diarrhoea and vomiting. The child was previously well
and was breast fed for six months only. The mother who is single had to start work as a
house help, so her 12 year old sister who is a school drop out looks after the child while
the mother is at work. She feeds the child on maize meal porridge and fresh cow’s milk.
They draw water from a well one kilometer away and the family uses a pit latrine.
On examination the child is afebrile. She is restless, irritable, and has sunken eyes. She
is thirsty and drinks eagerly and the skin pinch goes back slowly.
Problems to solve.
Using the above case, carry out a role play with one student acting the role of a health
worker and the other the role of the mother. In the process assess, classify and manage
Monde and give the mother advice on how she should take care of Monde at home.
Use the list below to help you in the role play
1. List all Monde’s signs of illness
2. Record how you would classify Monde’s dehydration and list all the signs that you
use to classify the dehydration
3. Look at the treatment plan under the classification in which you put Monde and
describe how you would manage her.
4. What would you tell Monde’s mother about how to treat the child at home? What
would you do to help her manage the child at home?
5. What would you tell her about how to manage the next attack of diarrhoea in case it
occurs?
6. What would you tell her about how to prevent occurrence of similar attacks in future?
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CASE ILLUSTRATION 2
Mukasa is a six month old male from Kisugu who was admitted in Kawempe health
centre 10 days ago with diarrhoea. His condition appears to have deteriorated with
swinging temperatures. He refuses to breast feed and appears to be uncomfortable and
crying most of the time. On examination Mukasa looks toxic and in pain.
Problem to solve
List all Mukasa’s signs of illness
Record how you would review Mukasa’s history of his illness, emphasizing previous
treatments before admission to the health centre.
Reexamine Mukasa to establish the possible cause of Mukasa’s illness.
How should the health centre staff have managed this baby?
AETIOLOGYAND EPIDEMIOLOGY
N.B: Students should widely consult and fill in and expand this table.
Types of diarrhoea
Three clinical syndromes of diarrhoea described below have been defined, each
reflecting a different approach to treatment.
The term refers to diarrhoea that begins acutely, lasts less than 14 days and involves
the passage of frequent watery stools without visible blood. Vomiting and fever may be
present. Acute watery diarrhoea causes dehydration and when food intake is reduced, it
also contributes to malnutrition. The main cause of death in acute watery diarrhoea is
dehydration often associated with delay in seeking care and inappropriate treatment at
home or in the health facility. Health workers must be aware of complications of
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anaemia and septicaemia as a result of traditional healers extracting infants’ teeth by
way of managing diarrhoea. The most important causes of acute watery diarrhoea in
young children in developing countries are rota virus, Escherichia coli, Campylobacter
jejuni, Vibrio cholera and Cryptosporidium.
Dysentery
This is diarrhoea with visible blood in the stool. Important effects of dysentery include
anorexia, severe abdominal pain and rapid weight loss. The main cause of dysentery is
Shigella. Some types of Escherichia coli and Salmonella may also be a cause.
Entamoeba histolytica can cause dysentery but it is rare in young children.
Persistent diarrhoea
This is diarrhoea that begins acutely but the duration is 14 days or more. It may begin
either as watery diarrhoea or as dysentery. Marked weight loss is frequent and
dehydration is a frequent finding. There is no single microbial cause for persistent
diarrhoea, shigella, enteropathogenic E. coli and cryptosporidium may play a greater
role than other causative agents. About 10 percent of acute diarrhoea episodes become
persistent. It is commonly associated with malnutrition, recent introduction of animal
milk feed, young age intercurrent infections and infection and immunological
impairment. It is associated with increased mortality, contributing to 35 percent of the
diarrhoeal deaths.
Epidemiology of Diarrhoea
Transmission of agents that cause diarrhoea
The infectious agents that cause diarrhoea are usually spread by the faecal-oral route,
which includes the ingestion of faecally contaminated water or food and direct contact
with infected faeces.
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Age
Most diarrhoeal episodes occur during the first two years of life. The incidence is
highest in the age group 1-11 months especially when complementary feeding is
introduced. This reflects combined effects of declining levels of maternally acquired
antibodies, lack of active immunity in the infant, the introduction of food that may be
contaminated by bacteria and direct contact with human and or animal feaces when the
infant crawls.
Seasonality
Distinct seasonal patterns occur in many geographical areas. In tropical areas, rota
virus diarrhoea occurs throughout the year, increasing in frequency during the drier,
cool months, whereas bacterial diarrhoea peak during the warmer rainy season.
Asymptomatic infections
Most enteric infections are asymptomatic, the proportion of which increase beyond two
years of age 1owing to the development of active immunity. During asymptomatic
infections which may last several days or weeks, stools contain infectious agents.
People with asymptomatic infections play an important role in the spread of enteric
pathogens, especially as they are unaware of their infection and take no special
hygienic precaution.
Epidemics
Two enteric pathogens, Vibrio cholera 01 and 0134 and Shigella dysenteriae type 1
(Shigella shigae), cause major epidemics especially in the developing countries in which
morbidity and mortality in all age groups may be high.
Aetiology
Pathogenic organisms are identifiable in as much as 75 per cent of patients with
diarrhoea. The organisms most frequently associated with diarrhoea in young children
are shown in Table 1 below.
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Table 1: Pathogens frequently identified in children with acute diarrhoea in developing
countries
Pathogen Percentage of
Recommended
cases antimicrobial
treatment
Virus Rota virus 15-25
None
Bacteria Enterotoxigenic and
enteropathogenic E. coli 10-25
None
Shigella 5-10
Nalidixic
acid
Campylobacter jejuni 10-15
None
Vibrio cholera 01 5-10
Tetracycline*
and 0134
Cotrimoxazole
Salmonella (non-typhi) 1-5
None
Protozoa Cryptospridium 5-15
None
No pathogen found 20-30
None
*
Tetracycline is contra-indicated in children below eight years of age
Rotavirus
This is the most important cause of severe, life-threatening diarrhoea in children under 2
years of age worldwide. There are four sero-types. Infection with one serotype causes a
high level immunity to that serotype and partial immunity against the other serotypes.
Nearly all children are infected before the age of two years and repeat infections are
uncommon. Rotavirus is probably spread by person to person transmission.
Enteropathogenic E. coli (ETEC)
This is an important cause of diarrhoea in both adults and children. The diarrhoea it
causes is mediated by toxins closely related to cholera toxin. It is spread by means of
contaminated water and food.
Shigella
Shigella is the most important cause of dysentery, being found in about 60 per cent of
all episodes and in nearly all severe episodes. There are four serotype: S. sonnei, S.
boydii, S. flexneri and S. dysenteriae. S. flexneri is the most common serotype in
developing countries, but S.dysenteriae type 1, causes the most severe disease. It is
spread mostly by person to person transmission.
Antimicrobials to which Shigella are sensitive provide effective treatment, but resistance
is common. The most useful antimicrobials are nalidixic acid and ciprofloxacin.
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Campylobacter jejuni
In developing countries, C. jejuni causes disease mostly in infants. It also infects
animals, especially dogs and chickens and is spread by contact with their feaces or
consumption of contaminated food, milk and water.
Vibrio cholera
V. cholera causes non-invasive diarrhoea which is mediated by toxins and extensive
coverage of the villae by the bacteria adhering to their surfaces. Antimicrobials can
shorten the duration of the illness. Tetracycline is widely used, but because of
resistance, other antimicrobials effectively used are cotrimoxazole, furazolidine or
chloramphenicol.
Enteric pathogens can also be found in about 30 percent of healthy children, making it
difficult to know whether a pathogen isolated from a child with diarrhoea is actually the
cause of that child’s illness. This is especially true for Giardia lamblia, enteropathogenic
E. coli and Campylobacter jejuni. On the other hand, Shigella and rotavirus are rarely
identified in healthy children, their presence in a child with diarrhoea is a strong
aetiological evidence.
Table 1 shows that antimicrobial agents are recommended only when infections with
shigella or V. cholera is suspected on the basis of clinical signs (especially in
epidemics) or confirmed by laboratory investigations. For all other agents and thus the
majority of acute diarrhoea episodes in young children, antimicrobials are either
ineffective or inappropriate. For agents such as salmonella the use of antimicrobials can
actually prolong the intestinal infection.
A number of other pathogens are not shown in Table 1 can cause acute diarrhoea in
children in developing countries but their role is either minimal or not well defined yet.
They include a number of viruses, bacteria and protozoa.
Other conditions associated with diarrhoea (see the guide to aetiological causes of
diarrhoea)
Children with infections such as malaria, urinary tract infections and other systemic
infections may present with diarrhoea. It is important that these conditions be identified
and appropriate treatment be given besides ORS. NB: Never give antibiotics to a child
presenting with diarrhoea and fever before confirming the absence of meningitis. It may
lead to partially treated meningitis with subsequent permanent mental damage.
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Viruses such as rotavirus, replicate within the villous epithelium of the small bowel,
causing patchy epithelial cell destruction and villous shortening.
Pathophysiology
Watery diarrhoea is caused by a disturbance in the mechanism of transport of water
and electrolytes especially sodium and chloride in the small intestines, and this is the
basis of management of diarrhoea through oral rehydration therapy and feeding.
Normally, sodium is actively absorbed from the bowel lumen by the villous epithelial
cells (Fig.1). After this sodium is transported out of the epithelial cells into the
extracellular fluid (ECF) by an ion pump known as Na+K+ ATPase. This creates an
osmotic gradient that facilitates absorption of water. There are several mechanisms
through which sodium is absorbed in the gut (Fig 2). Sodium linked to chloride iron
direct as sodium ion
Exchanged for hydrogen ion and linked to the absorption of organic substances such as
glucose or amino acids, a mechanism that is less affected even under disease
conditions. Secretion of water and electrolytes on the other hand occurs in the crypts of
the small bowel epithelium where sodium chloride is transported from the ECF into the
epithelial cells where sodium is pumped back into the ECF, but chloride is passed into
the lumen. Interference with these two mechanisms leads to more secretion than usual
plus reduced absorption as occurs with infections, will lead to diarrhoea.
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All the acute effects of watery diarrhoea are caused by the loss of water and electrolytes
from the body. Additional amount of water and electrolytes are lost when there is
vomiting. It is further increased by fever. These losses lead to dehydration, acidosis and
potassium depletion. The water and electrolytes loss are normally compensated for by
water and salt intake in drinks and food.
DEHYDRATION
This is the most dangerous complication because it can cause decreased blood volume
(hypovolaemia), cardiovascular collapse and death if not treated promptly. Dehydration
is more severe in children because, children have a higher percentage of body water
(70-75 percent) compared to adults (55-60 percent). In addition, water intake in children
is less and vomiting is more frequent contributing to the fluid deficit.
Biochemically, dehydration can be classified as: isotonic, hypotonic and hypertonic.
Isotonic dehydration
This is the most common type of dehydration caused by diarrhoea. There is equal
loss of water and electrolytes and it is characterized by:
Balanced deficit of water and sodium
Normal serum sodium concentration (130-150 mmol/l)
Normal serum osmolarity (275-295 mOsmol/l)
Substantial loss of extracellular fluid
Hypotonic dehydration
Loss of electrolytes more than that of water. There may be excess intake of plain
water, or intravenous infusion of 5 percent glucose in water. It is characterized by:
Deficit of water and sodium but with a greater deficit of sodium
Low serum sodium concentration (<130 mmol/l)
Low serum osmolarity (<275 mmol/l)
Hpertonic dehydration
There is increased water loss compared to electrolyte loss. May result from increased
intake during diarrhoea of hypertonic fluids (such as sugar salt solutions) or
insufficient intake of water. It is characterized by:
Deficit of water and sodium but there is more water deficit
Elevated serum sodium concentration (>150 mmol/l)
Elevated serum osmolarity (>295 mOsmol/l)
Severe thirst out of proportion to the degree of dehydration
Seizures may occur, especially when serum sodium concentration exceeds 165
mmol/l
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PRINCIPLES OF MANAGEMENT OF DIARRHOEA AND DEHYDRATION
Rehydration therapy
The goal in managing diarrhoea is to correct deficit of fluid and electrolytes
(rehydration therapy), and then replace further losses as they occur until diarrhoea
stops (maintenance therapy). The mainstay of management of diarrhoea is oral
rehydration therapy (ORT) supported by zinc supplementation. The majority of
diarrhoea and dehydration are effectively managed by use of this method. Only in very
severe dehydration, is intravenous rehydration indicated during the resuscitation phase,
followed by ORT.
Feeding
All children with diarrhoea should be given plenty of food to prevent malnutrition. For
children less than 6 months continue breast feeding. Breast milk is the best food for
young babies. If the child is six months or older, or is already taking solid food, give
cereals or another starchy food mixed with vegetables, pulses, meat and fish. Add one
or two teaspoonfuls of oil to each serving to increase energy supply.
Dairy products and eggs are also suitable foods for children with diarrhoea. Fresh fruits
or fresh juices should be given because they provide potassium. During the diarrhoeal
episode, offer food more frequently at least six times a day. After the diarrhoea stops,
offer the same food and give an extra meal each day for two weeks.
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Diagnose concurrent illness, such as meningitis, septicaemia resulting in some
traditional treatment of diarrhoea and pneumonia
Determine the child’s immunization status, especially that of measles
Delete the sections highlighted and use table 12 in the WHO pocket book of Hospital
care for children
NB skin turgor is not reliable in a malnourished child. Sunken fontanelle in babies can
also be used.
A child is in shock when the following are present: cold extremities, weak peripheral
pulses, low blood pressure and reduced urine output.
To decide on the presence and degree of dehydration of dehydration, one needs at
least 2 (two) of the four signs shown in Table 3. Once the degree of dehydration has
been made, the treatment plans A, B or C should be used as appropriate.
115
In this space insert charts 13, 14, and 15 i.e. plans A, B, and C of diarrhoea treatment
from the WHO pocket book of hospital care for children
Age < 4 4-11 12-23 2-4 yrs 5-14 yrs 15 yrs and
months mo mo older
Weight < 5 kg 5-7.9 8-10.9 11-15.9 16-29.9 30 kg or
kg kg kg kg more
In mls. 200-400 400- 600-800 800-1200 1200- 2200-4000
600 2200
In mls. 375 592.5- 817.5- 1192.5- 1200- 2250
based on 600 825 1200 2242.5
75
mls/Kg
116
oedematous (kwashiorkor or marasmic kwashiorkor) or severe non-oedematous
malnutrition (marasmus). Children who are malnourished must be given prescribed
feeding treatment to provide 100-200 calories per kilogramme body weight per day and
four (4) grammes of protein per kilogramme body weight per day.
Figure 6: Assessment of the Patient for other problems
PREVENTION OF DAIRRHOEA
It is important to teach communities on steps to prevent diarrhoea and these include:
Exclusive breastfeeding
Appropriate complementary feeding
Hygienic preparation and storage of food at all times
Clean drinking water
Hand washing before feeding and use of the toilet
Safe disposal of stools for all (including those of small children)
Complete immunization especially measles
REFERENCE:
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CHAPTER 9
INTRODUCTION
Acute respiratory infections (ARI) can be divided into upper respiratory tract infections
(URTI) and lower respiratory tract infections (LRTI). The former consists of common
cold, otitis media, sinusitis, pharyngitis, and tonsillitis, while the latter includes laryngo-
tracheobronchitis (LTB), bronchiolitis, and pneumonia.
Learning Objectives
By the end of this chapter, the student should be able to:
Learning Activities
Assess, classify and outline treatment of children presenting with cough and difficulty in
breathing to the out-patient department
Participate in the management of a child admitted to the ward with severe pneumonia
from admission to discharge.
Manage a child presenting to the hospital with stridor.
Review the integrated management of childhood illness (IMCI) slides and/or video
covering the topic of acute respiratory infection in children
Familiarize yourself with the standardized ARI case management charts provided by
IMCI on child presenting with cough, and with stridor.
ARI is the most common cause of mortality in infants and young children. It contributes
to 20 – 50 percent of deaths among children less than five years of age in developing
countries. The majority of ARI deaths are due to pneumonia, a LRTI. Pneumonia
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together with diarrhoeal disease, malaria, malnutrition and human immunodeficiency
virus (HIV) infection contribute to over 75% of all the deaths in children under five years
in developing countries. This signifies the seriousness of these five childhood diseases.
Malnutrition a common disorder in children is a very significant risk factor for ARI in
children. Available evidence shows that prevalence of pneumonia among severely
malnourished children is as high as 72%, and that pneumonia occurs 19 times more
commonly in malnourished compared to well nourished children, and that pneumonia
death is 27 times more frequent in this high risk group.
Aetiology of Pneumonia
In developing countries, bacteria account for 30-60% of pneumonia, viruses for 25-40%,
and atypical pathogens such as opportunistic organisms for up to 25%. Mixed bacterial-
viral infection account for 10-15% of pneumonias. The specific aetiology (especially
with respect to bacteria) varies according to age of child, presence of malnutrition or of
underlying HIV infection.
In infants and young children under five years most common bacterial pathogen is
streptococcus pneumonia, followed by Haemophilus influenzae, and staphylococcus
aureus. In the older child in addition to streptococcus pneumonia and staphylococcus
aureus, mycoplasma pneumoniae, and Chlamydia pneumoniae cause disease.
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In addition to the above described pathogens, severely malnourished and HIV infected
immuno-suppressed children, are prone to gram negative bacterial pneumonia and
pneumocystis jiroveci pneumoniae (PCP), the latter seen especially in HIV infected
children under age 6 months and severely immuno-suppressed.
Guidelines developed by the World Health Organization (WHO) and UNICEF for
management of a child presenting with ARI emphasize the recognition and
management of ARI at out-patient level, be it at the dispensary, health centre, or
hospital out-patient department. They are simple enough to be effectively used by
community health workers and mothers to recognize early pneumonia, and therefore
seek attention early.
For objective management, the children are divided into two groups based on age as
follows: two months to five years (the young child) and under two months (the young
infant). This is shown in figures 2 and 3.
Every child presenting with cough and/or difficult breathing, it is important to determine
age, duration in days, whether they are breathing fast, have difficulty in breathing,
stridor or wheeze, fever, whether there is history of exposure to someone with TB in the
family, history of choking or sudden onset, know HIV infection, whether child has been
immunized against BCG, DPT, Hib or measles, and if there is personal or family history
of asthma. It is also important to determine if the child has symptoms suggesting very
severe illness as follows:
Danger Signs
In assessing the child with ARI, it is important to ask and look for clinical features or
“danger signs” that suggest severe illness, and are associated with high mortality risk.
Any child presenting with these danger signs (listed below) should be admitted into the
hospital for care.
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Child aged two months to five years, ask and look for:
Is the child able to drink?
Has he/she had convulsions?
Are they abnormally sleepy, or difficult to wake?
Do they have stridor when calm?
Are they severely malnourished?
Do they have chest indrawing?
Are they wheezing?
Child aged less than two months (young infant), all the above symptoms/signs are
important, plus the following:
Is the baby unable to feed?
Does he/she have fever (≥ 380C) or hypothermia (< 35.50C)?
The young infant is given special attention, because their ARI mortality is higher, and
their disease presentation and treatment are significantly different from older children.
Bacterial infections in young infants may present with non-specific clinical signs, making
it difficult to distinguish pneumonia from sepsis and meningitis, and can lead to severe
illness and death rapidly.
121
Table 1: Differential diagnosis of the Child Presenting with Cough
or Difficult breathing
After assessment, a child aged two months to five years with ARI should be placed into
one of the following categories of ARI:
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Very severe disease
Severe pneumonia
Pneumonia (non severe)
No pneumonia: cough or cold
A diagnosis of pneumonia may be made in any child with cough or difficult breathing
plus fast breathing defined by the following respiratory rates:
Age < 2 months: ≥ 60/minute
Age 2 – 11 months: ≥ 50/minute
Age 1 – 5 years: ≥ 40/minute
Any of the danger signs puts a child in the very severe disease category. In the
absence of danger signs, chest in-drawing characterized by the in-movement of the
lower chest wall when the child breaths in places them in the severe pneumonia
category. The presence of fast breathing in the absence of danger signs or chest in-
drawing places the child in the (non-severe) pneumonia category. Finally children with
no danger sign, no chest in-drawing, not breathing fast, have “no pneumonia: cough or
cold”.
All young infants under two months of age with pneumonia are severely ill, and must be
admitted to hospital for care. In this age group there are only three categories of ARI
illness, that is; Very severe disease, severe pneumonia, and no pneumonia: cough or
cold.
Investigations that may be carried out include pulse oximetry and chest x-ray in children
with severe forms of pneumonia, or children with HIV.
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Table 2: Classification of the Severity of Pneumonia
Treatment
Antibiotic Therapy
Alternatives:
IM or IV chloramphenicol (25mg/kg every 8 hours) until child improves, and then
continue oral chloramphenicol 4 times daily for total course of 10 days
124
IM or IV ceftrioxone 80mg/kg once daily
If child does not improve or deteriorates within 48 hours check for complications. If none
is apparent switch to
Chloramphenicol to gentamicin (dose as above) with cloxacillin (50mg/kg every 6
hours). When child improves continue on oral cloxacillin 4 times daily for total course of
21 days.
Ampicillin/gentamicin to cloxacillin/gentamicin
Give benzyl penicillin (50,000 units/kg IM or IV every 6 hours) for at least 3 days
If child improves switch to oral amoxicillin 25mg/kg twice a day for total antibiotic course
of 5 days.
If child does not improve or deteriorates within 48 hours:
Evaluate for complications of pneumonia (as for very severe pneumonia or atypical
pneumonia).
If there are no apparent complications, switch to IM or IV chloramphenicol until child
improves, then continue with oral chloramphenicol for a total course of 10 days
Oxygen Therapy
Oxygen should be given to ALL children with very severe pneumonia, and to children
with severe pneumonia who have respiratory rates ≥ 70/minute or severe lower chest
wall indrawing. Where pulse oximetry is available, give oxygen to all children with
oxygen saturation < 90%.
Continue with oxygen until signs of severe respiratory distress subside, or oxygen
saturation is stable above 90%. The nurse should check every 3 hours that nasal
catheters or prongs are in correct place and ensure no mucus is blocking them.
Supportive Care
Fever:
Above 380C, give paracetamol (15mg/kg every 6 hours)
Fluids:
Ensure adequate daily fluids
125
If able to take orally encourage continued breastfeeding, or other oral fluids. If unable to
take orally (reduced level of consciousness, convulsions, severe respiratory distress)
give intravenous fluids cautiously.
Wheeze:
Assess for asthma or bronchiolitis, provide rapid-acting bronchodilator (see chapter on
asthma)
Clear airways:
Clear nasal mucous, remove any thick secretions in the throat by gentle suction.
Nutrition:
Encourage mother to continue feeding the child.
Home Care Advise to the Mother for the Child with non-severe pneumonia.
Complications
If the child has not improved over 48 hours, or has worsened, evaluate for complications
or review the diagnosis. A chest x-ray and other investigations in accordance with the
suspected complication or alternative diagnosis should be sought. Common
complications of pneumonia include pneumatocele, pneumothorax, empyema, pleural
effusion. Possible alternative diagnoses are outlined in table 1.
Bronchiolitis
Children presenting with the first attack of wheeze may have bronchiolitis, especially if
they are less than one year old. Bronchiolitis is a lower respiratory viral infection which
typically is most severe in young infants, occurs in annual epidemics and is
characterized by airways obstruction and wheezing. Secondary bacterial infection may
occur, and is common in some settings. If in addition to wheeze the child has increased
respiratory rate and/or chest indrawing their disease should be managed as for
pneumonia.
Those children presenting with recurrent wheeze and features of pneumonia/severe
pneumonia should be treated first with a rapid acting bronchodilator such as inhaled
salbutamol (by metered dose inhaler and spacer, or nebulisation) or subcutaneous
adrenaline, and reviewed after 30 minutes. If the symptoms improve (reduced wheeze,
and respiratory rate) treat as asthma. If symptoms persist, treat as pneumonia.
126
EAR INFECTIONS
The most common ear infection is otitis media. This is an infection of the middle ear.
The middle ear is considered a part of the respiratory system. It is connected to the
pharynx by the eustachian tube.
Ear infections are caused by both viruses and bacteria similar to those that cause
pneumonia, that are streptococcus pneumoniae and haemophilus influenzae.
Ear infections rarely cause death, but they cause many days of illness. Sometimes the
infection can spread from the ear to the mastoid bone leading to mastoiditis, or to the
brain leading to brain abscess or meningitis. They, (ear infections) are the main causes
of deafness in the developing countries.
The common presenting features of ear infections are, fever, ear pain and pus
discharge from the affected ear. As for pneumonia children presenting with ear problem,
should he assessed, classified and treated.
The following are important in the assessment of a child presenting with an ear problem;
(I) Does the child have ear pain?
(2) Does the child have pus discharge from the ear? If yes, for how long;?
(3) If you have an otoscope find out if the ear drum is red and dull with no light
reflex. These strongly suggest ear infections
(4) Feel for tender swelling over the mastoid bone- that is behind the ear The point
of mastoid tenderness in young, infants may be above the ear-
Classifying a Child with an Ear infection
A child with an ear problem should be put into one of the following categories;
(1) Mastoiditis
(2) Acute Ear Infection
(3) Chronic Ear Infection
Mastoiditis
A child with a tender swelling behind the ear is classified as having Mastoiditis.
Such patients must be referred urgently for in patient treatment with parenteral
antibiotics similar to those used for pneumonia. Some of them may require surgery.
A child with pus discharge from the ear for less than two (2) weeks, or ear pain or a red
immobile ear drum has Acute Ear Infection.
The child should be given antibiotics to treat the Acute Ear- Infections. When there is
pus discharge, the treatment is wicking. This facilitates drying of the ear. Ear drops
127
should be avoided as they keep the ear moist, delay healing and do not reach the
infection.
A child who has had pus discharge from the ear for more than two weeks, has Chronic
Ear Infection. This is the main cause of deafness in children. The most important and
elective treatment, is keeping the ear dry by wicking.
Bacteria that are found in the ear two weeks after onset of pus discharge are due to
secondary infections. Commonly grown are bacteria such as peudomonas, proteus and
gram negative enteric organisms. Sometimes, fungi are isolated. A chronically draining
ear will heal only if it is dry. Drying the ear by wicking is time consuming but it is the
only effective therapy. The infections do not respond to antibiotics. Do not apply
any fluid into the ear.
THROAT INFECTIONS
Throat infections are common reasons for children seeking medical attention. Sore
throat is a major complaint that accompanies common colds. The large majority are
caused by viruses. They get better in a few clays with good home care and no
additional treatment. Antibiotics are not indicated in these patients. Most children only
need a safe, soothing remedy for the sore throat.
Streptococcal pharyngitis is more common in the age group five to 15 years and rare in
the under five year olds. It is treated with antibiotics to prevent the complication of acute
rheumatic fever and the subsequent acute rheumatic heart disease.
Assessment of a child presenting with Sore Throat
The following are important in the assessment of a child with a sore throat;
(1) Is the child able to drink?
(2) Does the child have an exudate in the throat?
(3) Does the child have enlarged tender cervical lymph nodes'?
128
(3) Simple viral sore throat
Throat Abscess
A child who is not able to drink at all is classified as having a Throat Abscess. Besides
this, they may present with drooling of saliva and tenderness at the angle of the jaw.
Although it is not common, children may develop abscesses behind the throat or around
the tonsils. The abscesses make it difficult for the child to swallow water. A child with
throat abscess should be referred for inpatient treatment and, if needed, to drain the
abscess. These patients should be given parenteral antibiotics such as benzylpenicillin
and chloramphenicol.
PREVENTION OF ARI
Standard ARI case as given in this chapter has greatly reduced deaths in the under
fives. Prevention of pneumonia on the other hand requires reduction of the risk factors
outlined earlier. Of particular importance is reduction in early childhood undernutrition
which is estimated to be the underlying cause of mortality in about 60% of deaths in the
under fives.
Avoiding overcrowding, cooking inside the house, and smoking are also important.
129
REFERENCES
Pocket book of hospital care for children: guidelines for management of common
illnesses with limited resources. WHO 2005
Shann F Etiology of severe pneumonia in children in developing countries Pediatr Infect
Dis 1986; 5:247-52
Forgie IM, O’Neill KP, Lloyd-Evans N et al Etiology of acute lower respiratory tract
infections in Gambian children: II Acute lower respiratory tract infection in children ages
one to nine years presenting at the hospital Pediatr Infect Dis 1991; 10:42-7
Forgie IM, O’Neill KP, Lloyd-Evans N et al Etiology of acute lower respiratory infections
in Gambian children: I Acute lower respiratory infections in infants presenting at the
hospital. Pediatr Infect Dis 1991; 10:33-4
130
CHAPTER 10
ASHMA IN CHILDREN
LEARNING OBJECTIVES
At the end of this chapter, the student should be able to
define asthma
list factors leading to the development of asthma
understand the pathogenesis of asthma
make a diagnosis of asthma
grade the severity of an acute exacerbation of asthma
treat a child with an acute exacerbation of asthma
classify severity of chronic asthma
manage a child with chronic asthma
educate patients and families on asthma prevention
Learning activities
Definition
The prevalence of asthma childhood in Africa ranges from 2% to 18% and seems to be
increasing.
Pathogenesis
The pathogenesis of asthma is unclear. It however has significant genetic and
environmental components. Host factors important for the development of asthma
include atopy, airway hyper responsiveness, obesity, and male sex. Environmental
factors include allergens (e. g house dust mite, pollen), viral infections (e. g rhinovirus),
and pollutants (e. g smoke) and exercise in dry cold weather.
Mechanisms of asthma
Though the clinical spectrum of asthma is variable, the presence of airway inflammation
is a constant feature. Inflammatory cells, i.e. mast cells, eosinophils, T- lymphocytes,
131
release bronchoconstrictor mediators and specific cytokines that are responsible for the
airway hyper responsiveness as well as epithelial damage and remodeling (figure 1).
Environment
. Allergens
. Infections
. Pollutants . Biological and
. Microbes genetic risk
. Stress . Atopy
Lower airway
injury
. Persistent inflammation
Aberrant . Airway hyper responsiveness
Repair . Remodeling
. Airways growth and
differentiation
ASTHMA
Diagnosis of asthma
Diagnosis of asthma is made on the basis of a history of recurrent cough and episodes
of wheezing. Physical findings may include audible wheeze with prolonged expiration.
Prompt response to bronchodilator may help in making a diagnosis of asthma.
The diagnosis can be strengthened by measuring the peak expiratory flow (PEF) which
provides an assessment of the severity of airflow obstruction as well as air flow
variability and reversibility.
Other causes of recurrent wheezing or persistent cough must be considered and
excluded, i.e. chronic rhino-sinusitis, gastro-oesophageal reflux disease, pulmonary
tuberculosis and foreign body aspiration. Children presenting with these conditions are
unlikely to respond to bronchodilator therapy.
132
Assessment of an acute exacerbation of Asthma
Table 1 : Severity of Asthma Exacerbations
Mild Moderate Severe Respiratory
arrest
imminent
Breathless Walking Talking infant At rest
Can lie down – softer Infant stops
shorter cry; feeding
Difficulty Hunched
feeding forward
Prefers sitting
Talks in Sentences Phrases Words
Alertness May be Usually Usually Drowsy or
agitated agitated agitated confused
Respiratory Increased Increased Often >
rate 30/min
Normal rates of breathing in awake children:
Age Normal Rate
< 2 months < 60/min
2-12 months < 50/min
1 – 5 years < 40/min
6 – 8 years < 30/min
Accessory Usually not Usually Usually Paradoxical
muscles thoraco-
and abdominal
suprasternal movement
retractions
Wheeze Moderate, Loud Usually loud Absence of
often only end wheeze
expiratory
Pulse/min < 100 100 – 120 > 120 Bradycardia
Guide to normal pulse rate in children
Infants 2 – 12 months – normal rate
< 160/min
Preschool 1 – 2 years
< 120/min
School-age 2 – 8 years
< 110/min
Sa O2 % (on > 95% 91 – 95% < 90%
air)
Hypercapnia (hypoventilation) develops more
readily in young children than in adults and
adolescents.
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Table 2. Management of acute exacerbation of asthma
Mild to Moderate Severe exacerbation Life-threatening asthma
exacerbation
Salbutamol Humidified oxygen by Admit to PICU or special
inhalation via nasal prongs or nasal ward and treat as for severe
spacer and mask: 2 catheter (1-2 l/min) exacerbation.
puffs every 10 Salbutamol inhalation or
minutes to a mobilization as for If not improving,
maximum of 10 moderate exacerbation Prepare for intubation and
puffs PLUS Mechanical ventilation
Inhaled ipratropium
If good responses bromide via spacer or
then reduce the nebulizer 4-6 hourly
frequency to 2-4 125 mcg< 1 year
puffs every 2 to 4 250 mcg if 1-5 years
hours. 500 mcg>5 years
AND
Or prednisolone PO
Salbutamol If poor response after 1 -2
nebulisation 2.5 hours or vomiting, give IV
mg<2 years 5 hydrocortisone 4 mg/kg
mg>2 years every 6 hours
AND
Start prednisolone If poor response after a
at beginning of further 2 hours give IV
treatment 1 mg/kg aminophylline
(Max 40 mg) PO 5 mg/kg infusion over 20
OD for 3 days min then slow infusion at
the rate 1 mg/kg/hour
Admit to wards
Discharge if Reassess every 2 hours
improving. If poor
response after 1-2
hours admit and
manage as severe
exacerbation
134
Classification of Asthma Severity by Clinical Features Before Treatment
135
Management of a child with chronic asthma
Patient education
136
b. Correct use of asthma medication including understanding the difference between
reliever and controller medication
c. Correct use of inhaler and devices (inhalers, spacers, masks, age appropriate)
d. Early recognition of acute asthma exacerbation and taking appropriate steps
Learning activity
To make a home-made spacer using a 500 ml drink bottle refer to the
WHO IMCI guidelines.
137
References
2. Standard Treatment Guidelines and Essential Drugs List for South Africa.
Paediatric Hospital Level. 1st Edition 1998.
7. Busse VW and Lemanske RF. Asthma. New Engl Jour of Med, February 2001,
Number 5, vol 344:350-362
8. GINA. Global strategy for asthma management and prevention 2007 report.
10. Zar HJ et al. Randomized controlled trial of the efficacy of a metered dose
Inhaler with bottle spacer for bronchodilator therapy in acute lower airways
obstruction.
Arch Dis Chil, doi: 10, 1136/adc.2006.101642.
11. WHO. Pocketbook of Hospital Care for Children. Guidelines for the management
of common illnesses with limited resources 2007.
12. Kenya association for the prevention of tuberculosis and lung disease (KAPLD).
Consensus statement on the management of asthma in Kenya, 2005.
138
CHAPTER 11
TUBERCULOSIS IN CHILDREN
INTRODUCTION
Tuberculosis (TB) is a major cause of illness and death worldwide especially in Asia and
Africa. Globally, there were an estimated 9.2 million new cases, and 1.7 million TB -
related deaths, of which approximately 400,000 were in children, and 0.2 million in HIV
positive individuals in 2006.
The emergence of HIV infection has grossly altered epidemiological patterns of TB.
About one third of the estimated 40 million people living with HIV worldwide are co-
infected with TB, and they have a five-fold higher mortality than in individuals with TB
alone.
Learning Objectives
Learning Experience
Practice taking a history in a child suspected to have TB
Assess for physical signs suggestive TB
Perform a and interpret tuberculin skin test
Participate in giving BCG to a newborn
Find out how your country manages to do contact tracing of children of parents with
sputum positive pulmonary TB
139
Children with severe malnutrition
HIV infected children
Post-measles or post-pertussis infection
Non-immunized children (higher risk of severe tuberculous disease)
Other immuno-suppressive states such as diabetes mellitus, malignancies, steroid
therapy etc.
Children are more likely to progress to active TB disease than adults, with infants and
children under 5 years at greatest risk. Those who do not develop active TB disease are
described as having latent TB. The likelihood of developing disease is highest shortly
after exposure (6 – 8 weeks) and decreases with time.
Routes of infection
The bacilli may enter the human body by any of the following routes:
Inhalation
Ingestion
Inoculation
Inhalation of bacilli through the respiratory tract is by far the most common portal of
entry (over 98% of cases); inhaled bacilli settle in the lower respiratory tract.
Local infection at the portal of entry is usually followed by spread to regional lymph
nodes (primary complex). In most children, this primary infection remains quiescent but
may result in progression of disease in any of the following ways:
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Within the lung: multiplication of bacilli initially within alveoli and alveolar ducts before
spreading to the lung parenchyma and pleura to cause tuberculous pneumonia,
pleurisy, and in older children, pleural effusion and cavitation
hilar lymph node inflammation and enlargement, leading to compression of bronchi
which leads to lobar or segmental collapse (atelectasis)
tonsillar infection: spread to cervical lymph nodes
haematogenous (and lymphatic) spread, leading to military TB, involving the lung,
pericardium, meninges, abdomen, bone and joint
Enlarged focus (coin shadow).
Development of any of the above lesions largely depends on immune status of the
individual child as well as BCG vaccination status.
The table below shows the approximate time frame within which each of the
pathological lesions develops:
5 Up to 12 yrs Genitourinary
In addition to the general symptoms described above, depending on the site of the
active TB infection, the child may develop symptoms and signs specific to the site of the
active infection. These clinical features are described below:
Pulmonary TB
This is the commonest form of TB occurring in children. There excessive sweating,
tachypnoea, respiratory distress, nausea and vomiting. Younger children may present
with wheezing due to bronchial obstruction by enlarged hilar lymph nodes (primary
complex). Even with more than one lobe involvement in young children respiratory signs
may be absent. Older children and adolescents may present with similar disease to
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adults with productive cough; sputum may be purulent or blood stained (haemoptysis)
and there may be signs of apical lobar consolidation and in advanced disease,
cavitation.
Pleural effusion
This tends to occur in older children. They presents with progressive breathlessness
(dyspnoea), chest pain, tracheal shift away from affected side, stony dull percussion
note, and may have a pleural rub (in early stages) and reduced breath sounds over the
affected lung. They may or may not have cough.
Abdominal TB
Tuberculous infection in the abdomen may present with progressive abdominal swelling
and abdominal pain associated with persistent fever and weight loss. Examination may
reveal abdominal distension with ascites, abdominal mass (enlarged lymph nodes),
enlarged liver and/or spleen. Progressive intestinal obstruction by enlarged lymph
nodes may manifest as constipation with vomiting, and abdominal distension.
Commonly involved tissues include the jejunum, ileum, Payer’s patches and appendix.
Generalized peritonitis may occur, though not common.
TB Meningitis
The clinical presentation of TB meningitis can be described in three stages as follows:
Stage I: Child presents with non-specific symptoms and signs of persistent fever,
headache, irritability and drowsiness (1-2 weeks).
Stage II: Progression to more specific symptoms and signs of meningeal irritation –
neck stiffness, positive Kerning’s sign, positive Brudzinski sign, convulsions, hypertonia,
vomiting, cranial nerve palsies and focal neurological signs.
Stage III: Child develops features of severe neurological disease including coma,
hemiplegia, decerebrate or decorticate posturing and abnormal vital signs.
Tuberculous meningitis may be differentiated from pyogenic meningitis due to the
insidious onset of symptoms (over weeks) and long history of ill health, as compared to
the acute onset (over days) of pyogenic meningitis
Tuberculoma
Tuberculomas present with features of space occupying lesions in accordance with their
location within the brain. Accompanying symptoms include headache, persistent fever,
weight loss or poor weight gain. Parietal lesions will cause paraparesis or hemiparesis
and progress to full paraplegia or hemiplegia. Children may in addition develop features
of raised intra-cranial pressure such as vomiting and diplopia.
Osteo-articular TB
This is caused by haematogenous spread of TB bacilli, initially infecting the metaphyses
of weight-bearing bones and joints (vertebrae, knee, hip, elbow and ankle), and may
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manifest several months to years after the primary TB infection. The child presents with
initially mild pain, swelling at the site, with minimal or no tenderness, refusal to use the
limb, associated persistent low-grade fever and poor weight gain.
TB of the vertebra (Pott’s disease) presents initially with mild back pain which slowly
gets worse, abnormal posturing and reluctance to walk, progressing to inability to walk.
Examination may reveal rigidity of spine, minimal or no tenderness and abnormal
curvature of spine; in advanced stages, collapse of the vertebral body may lead to
formation of a gibbus (pathognomonic of TB spine), and to spinal compression with
resultant loss of motor function of the lower limbs and loss of bladder and anal sphincter
control.
Specimens may be obtained from suspected site of infection, and include sputum
(pulmonary TB), pleural aspirate (pleural effusion), lymph node aspirate or biopsy (TB
lymphadenitis), cerebro-spinal fluid (TB meningitis), ascitic tap or fine needle aspirate
(FNA) from abdominal mass (abdominal TB), joint aspirate (TB arthritis) etc.
143
Box 1: Key features suggestive of TB
The presence of three or more of the following should strongly suggest a diagnosis
of TB
Chronic symptoms suggestive of TB
Physical signs highly suggestive of TB
A positive tuberculin skin test
Chest X-ray suggestive of TB
b. Extra pulmonary TB
Physical signs highly suggestive of extra pulmonary TB include:
non-painful enlarged cervical lymphadenopathy with fistula (abscess) formation
Gibbus, (deformity of spine resulting from vertebral TB) especially of recent onset.
Physical signs requiring investigation to exclude or support diagnosis of extra
pulmonary TB
Meningitis with a sub-acute onset (developing over several days to weeks), not
responding to standard anti-meningitic antibiotic treatment.
Pleural effusion, one sided.
Distended abdomen with ascites with or without palpable lumps.
Non-painful enlarged lymph nodes without fistula (abscess) formation
Non-painful swelling or deformity of bone or joint.
In addition, documented weight loss or failure to gain weight, especially in child with
adequate nutritional intake, is a good indicator of chronic disease in children, of which
TB may be the cause.
Investigations relevant to rule out or support diagnosis of extra-pulmonary TB
Site of Suspected TB Infection Practical approach to diagnosis
Peripheral lymph nodes Lymph node biopsy or fine needle aspiration
Miliary TB (disseminated) Chest X-ray and lumbar puncture
TB meningitis Lumbar puncture (CT scan where available)
Pleural effusion Chest Xray, pleural tap
Abdominal TB Abdominal ultrasound, ascitic tap
Osteo-articular X-ray of bone/joint, joint tap or synovial
biopsy
Pericardial TB Ultrasound, pericardial tap
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All specimens should be subjected to microscopy (acid fast bacilli stains and white cell
counts) and mycobacterial cultures. Biopsy specimens should also be subjected to
histology. CSF, pleural, ascitic, and pericardial aspirates should also be subjected to
biochemical analysis (protein and glucose concentrations). Laboratory tests are
discussed in greater detail below.
(It is important to appreciate that in the high risk children, a negative TST reaction may
be a false negative, i.e. does not rule out the presence of M.TB infection in this group of
children)
Persistent opacification in the lung with enlarged hilar or subcarinal lymph nodes.
Miliary pattern of opacification in both lungs
Large pleural effusions*
Apical infiltrates with or without cavity formation*
Enlarged hilar adenopathy with lobar collapse*
*These radiological pictures are seen mainly in older children and adolescents.
Bacteriologic Confirmation
Obtaining specimens
Sputum may be obtained through expectoration by child, sputum induction, or removal
of swallowed sputum by aspiration of gastric contents early in the morning.
145
Expectoration:
Older children (>8years) should be encouraged to cough up sputum into a sputum
container. Ideally 2-3 specimens should be obtained; an on-the-spot specimen (at first
clinical evaluation), an early morning specimen, and a second on-the-spot specimen (at
a follow-up visit)
Gastric aspiration: Lay the child on their back or side, attach a syringe to the
nasogastric tube, then insert the NGT into the stomach. Withdraw (aspirate) 5-10ml of
gastric contents. If no fluid is aspirated, insert 5-10ml of normal saline and attempt to
aspirate again. Transfer the aspirate to a sterile container (sputum collection container).
Add an equal volume of sodium bicarbonate solution to the specimen (neutralizes acid
and prevents destruction of TB bacilli).
Laboratory Assays
Microscopy
Common stains for identification of M.TB include Ziehl Nielssen staining, an acid-fast
stain in which mycobacteria appear as pinkish-red bacilli. Immunofluorescent staining is
more sensitive in identification of the bacilli, however requires a specialized microscope.
Specimen culture
Mycobacteria may be cultured using:
- Solid media such as Lowenstein Jensen – result in 3-8 weeks.
- Liquid media such as Liquid Bactec (media observed drug susceptibility) result in 5-14
days.
Biochemical analysis of specimens (CSF, aspirates):
High protein levels
Low glucose levels
Treatment of Tuberculosis
Goals of treatment
Clinical cure
Restoration of normal growth and development
Restoration of normal childhood activities
Prevention of transmission to other children
Prevention of relapse
Prevention of drug resistance
Approach to treatment
Currently available anti-TB drugs are either bactericidal or bacteriostatic.
Combination therapy in treatment of TB is the golden rule and monotherapy is strongly
discouraged since drug resistance is highly likely to occur given the long duration of
therapy.
Development of appropriate anti-TB regimens is based on the fact that:
a) Most children have pauci bacillary pulmonary disease
b) Extra-pulmonary TB is more common in children than adults
c) Severe and disseminated TB occurs mainly in very young children (below 3 years)
146
Recommended treatment regimens
Anti-TB treatment is given in two phases:
1) Intensive phase
The purpose of the intensive phase is to rapidly eliminate most of the organisms and to
prevent emergence of drug resistance; this phase, therefore uses more drugs than the
continuation phase.
2) Continuation phase
This phase is intended to eradicate dormant bacilli and thus uses fewer drugs.
Regimen
Diagnosti TB Cases Intensive Continuation
c Phase Phase
Category
- New smear-positive pulmonary TB
Ia - New smear-negative pulmonary TB
with extensive parenchymal
Involvement 2RHZE 4RH
- Severe forms of extra-pulmonary TB
other than TB meningitis (miliary TB,
spinal TB, abdominal TB, renal TB,
adrenal TB, TB pericarditis, bone and
joint TB, etc)
- Severe concurrent HIV disease
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* Note that in treatment of TB meningitis, streptomycin replaces ethambutol since
the latter does not cross the blood – brain barrier
The diagnosis and treatment of TB in the HIV infected child has several challenges
which shall be outlined in this section.
Diagnosis
Chronic symptoms
HIV infected children frequently have recurrent or persistent HIV-related illnesses and
consequently the chronic symptoms suggestive of TB (chronic cough, persistent fever,
weight loss or poor weight gain) are frequently present in the HIV infected child as part
of HIV disease itself, and could suggest TB or many other underlying HIV-related
diseases.
Physical sign:
Due to their deteriorating immunity, HIV infected children with pneumonia or meningitis
frequently respond poorly to antibiotic therapy, as such, this sign may suggest TB, but
may also suggest many other pathogenic infections.
Because of the above reasons, TB may be over-diagnosed in these children due to high
frequency of symptoms and signs suggestive of TB that they may present with.
However TB may also be missed due to atypical presentation, anergic TST and
negative bacteriologic tests.
In approaching diagnosis of TB in an HIV infected child, one should use the same
approach as outlined above – microbiologic diagnosis, and /or clinical diagnosis by
evaluating for suggestive symptoms, signs, radiology and positive TST. One must have
a higher index of suspicion in these children.
148
Child will require anti-TB drugs as well as antiretroviral drugs (6 drugs), consideration to
timing of initiation of both therapies, and selection of drugs with consideration of drug
interactions.
Consideration of adverse effects of drugs
Severely immuno-suppressed children may have severe forms of TB slower response
to anti-TB therapy, therefore may require more aggressive therapy
increase the dose of nevirapine by 30% during the period of anti-TB therapy (monitor
closely for NVP adverse effects), or boost lopinavir with additional ritonavir to achieve
LPV: r in 1:1.
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Acceptable ART regimens for use with rifampicin:
Prevention of infection is therefore the most realistic way to control the TB epidemic and
should form the basis of all TB control programmes. Preventive measures take different
forms:
1. Prevention of infection:
Prevent contact with individuals likely to have sputum-positive pulmonary TB.
Prompt diagnosis and treatment of suspected cases of pulmonary TB using appropriate
combination therapy.
Contact tracing and treatment.
4. Health education:
Ensure that all people (especially community leaders) understand
The epidemiological importance of TB
The common symptoms and signs of TB
The importance of completion of therapy
150
REFERENCES
Jeena PM, Pillay P, Pillay T and Coovadia HM. Impact of HIV-1 co-infection on
presentation and hospital related mortality in children with culture proved pulmonary
tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis 2002;6:672-678.
Mukadi YD, Wiktor SZ, Coulibaly IM et al Impact of HIV infection on the development
and clinical presentation and outcome of tuberculosis among children in Cote d’Ivoire.
AIDS 1997;11:1151-1158.
La Porte CJ, Colbers EP, Bertz R, Voncken DS, Wikstrom K, Boeree MJ, Koopmans
PP, Hekster YA, Burger DM. Pharmacokinetics of adjusted-dose lopinavir-ritonavir
combined with rifampin in healthy volunteers. Antimicrob Agents Chemother. 2004
May;48(5):1553-60.
Madhi SA, Huebner RE, Doedens L, Aduc T, Wesley D, and Cooper PA. HIV-1 co-
infection in children hospitalised with tuberculosis in South Africa. Int J Tuberc Lung Dis
2000:448-454.
Niemi M, Backman JT, Fromm MF, Neuvonen PJ, Kivisto KT. Pharmacokinetic
interactions with rifampicin: clinical relevance. Clin Pharmacokinet. 2003;42(9):819-50.
151
CHAPTER 12
MALARIA IN CHILDREN
INTRODUCTION
It has been estimated that 90% of the African population live in malarious zones and
malaria is a direct cause of approximately 12% of all deaths of African children below
five years of age. Malaria is, therefore a threat to child survival and development. It is a
major cause of foetal loss and low birth-weight (LBW) particularly in primiparous
mothers. The risk of severe malaria is greatest during pregnancy, early puerperium,
early childhood and in individuals where malaria coexists with other infections, stress or
chronic diseases and in individuals with little or no immunity to malaria.
Over the last 10 years, management of malaria has been bogged down by high
resistance of P. Falciparum to choroquine, sulphadoxine-pyrimethamine. Currently,
artemesinin containing combinations are recommended at Primary Health Care level.
Protein energy malnutrition (PEM), anaemia and malaria often coexist and aggravate
each other. The effect of malaria, starting from pregnancy (anaemia, LBW and
abortion), infancy (anaemia and death) and young children can result in:-
Sapping the energy and growth in children
Poor education and stunted growth in children
Low work output
Reduced or slow economic development
Therefore, control of malaria as an integral part of Primary Health Care (PHC) is very
important for a health community
OBJECTIVES
At the end of this chapter, the student should be able to:-
152
LEARNING ACTIVITIES
During your paediatric rotation, make a clinical diagnosis of malaria and confirm it by
laboratory investigations
During your paediatric rotation, note the number of children admitted with malaria and
the major complications.
During your community assignment, estimate the frequency of malaria in schools based
on the frequency of anemia, hepato-splenomegaly and positive blood smear;
During your community assignment, determine the availability and common use of
antimalarial drugs.
The following are methods used to estimate the prevalence of malaria in a community:-
1. Spleen Rate
This method estimates the proportion of children in the age group two to ten
years who have splenomegaly (see table 1 below)
The low adult spleen rates in holoendemic areas indicate considerable immunity
acquired by intense exposure to perennial transmission.
153
2. Parasite Rate
This is a proportion of the population in which malaria parasites are found using
blood films.
3. Parasite Count
This can be reported as parasites against leucocyte count for exact amount of
blood related to a count. (parasites/µl)
PATHOGENESIS OF MALARIA
Haemolysis and tissue ischaemia account for the majority of pathophysiological
changes. The higher the parasite could worsen the prognosis. Release of interleukins
from infected erythrocytes is responsible for clinical features such as fever.
Infected erythrocytes become sticky and are coated with fibrin which causes
agglutination and obstruction in small vessels, this leading to local hypoxia. In addition,
the following disturbances may occur:-
1. Anaemia
More severe with P.Falciparum because it invades red blood cells of all ages
and frequently produces a high level of parasitaemia;
2. Hypoglycaemia
Occurs due to depleted glycogen stores and competition for serum glucose by the
parasite. Reduced food intake and the increased secretion of insulin in patients treated
with quinine also contribute to hypoglycemia. There may also be use of traditional
herbs that contribute to protracted hypoglycaemia.
3. Thrombocytopenia
Can occur due to splenic sequestration and bone marrow depression
154
expansion occurring as a compensatory response to the vasodilatation
caused by malaria toxins;
7. Acidosis can occur due to increased lactate and pyruvate production as the
parasites use glucose;
Splenomegaly occurs due to hyperplasia of reticuloendothelial system and
vascular congestion. Tropical splenomegaly syndrome (TSS) occurs due to
an abnormal immune response to persistent malarial antigen stimulation in
an endemic region;
9. In the brain parasitized red blood cells are preferentially sequestrated in deep
capillaries causing clogging and subsequent ischemic changes, congestion,
oedema and central nervous system manifestations.
CLINICAL FEATURES
The clinical picture of malaria in children depends on child's age and immunity.
The non-immune infants and children who contract malaria for the first time also have a
variable clinical picture. They may present with restlessness, drowsiness, listlessness
or refusal to feed. They may also have headache, nausea and pallor. A clear cut cold
stage and rigor are uncommon. Vomiting can be severe causing dehydration and
electrolyte imbalance. Fever is invariable, often continuous although it may also be
irregular. Convulsions often occur. Signs of cerebral malaria include fever, impaired or
loss of consciousness, convulsions, with normal cerebral-spinal findings.
DIAGNOSIS OF MALARIA
Definite diagnosis of malaria is made by establishing the presence of malaria parasites
in the blood by examining a blood smear. However, due to delays in blood testing in
developing countries, malaria should be suspected in all cases of fever in endemic
areas. Proper history taking and physical examination is mandatory to differentiate
malaria from other febrile conditions such as urinary tract infection, meningitis, tonsillitis,
viral infection, etc. Some investigations (other than a blood smear) may be necessary
in order to exclude the coexistence of other infections. A malaria negative blood slide
does not exclude malaria infection. Diagnosis of malaria may also be made by detection
of antibodies in the blood using the rapid diagnostic tests (RDT's). Since malarial
antibodies persist in the blood of the patient after the infection, these tests are therefore
only useful for surveys or research work and in subjects in whom parasites are difficult
to find.
Counting Malaria Parasites in a blood film using parasite per micro litre method
Counting malaria parasites reflects the degree of parasitaemia, which in turn is related
to prognosis.
A thick blood film is made and examined under the oil objective of a microscope. Two
hundred leucocytes are counted using a tally counter. At the same time using a
separate tally counter, the number of malaria parasites in the fields is counted. When
155
10 malaria parasites or more are counted in the fields where 200 leucocyte have been
counted, then the result is rerecorded showing parasites per 200 leucocytes. If after
counting 200 leucocytes 9 or less parasites are counted, counting is continued until 500
leucocytes. Parasites are recorded per 500 leucocytes. Parasite count is then
converted to parasites per micro litre using the mathematical formula below:
Number of parasites x 8000 = Parasites per micro litre
Number of leucocytes
COMPLICATIONS OF MALARIA
A. Falciparum Malaria
The high invasive power of P.Falciparum leads to the rapid destruction of erythrocytes
and the resulting anaemia can be very severe. Infections in which five to twenty percent
of red blood cells contain parasites are uncommon. The progressive destruction of red
blood cells leads to anaemia. Micro thrombi thrombi are formed by parasitized red blood
cells leading to local anoxia of various organs. The resulting changes in the various
organs e.g. the brain, liver, kidney, bone marrow, lungs, etc. are responsible for
complications. The complications can be very severe in those with low immunity.
Severe infections occur in endemic regions, most commonly between the ages of six
months to three years and are responsible for almost all the deaths directly attributable
to malaria in these areas.
These severe attacks can develop with great suddenness and manifest themselves as:-
Hyperparasitaemia: The density of the asexual forms in the peripheral blood exceeds
5% of the red blood cells or parasites per micro litre
Cerebral malaria;
Gastrointestinal malaria with diarrhoea and vomiting;
Hyperpyrexia; (T > 39o rectally)
Severe anaemia (packed cell volume of less than 20%);
Algid malaria which presents as peripheral vascular collapse due to adrenal failure; may
have concurrent gram negative septicaemia
Black water fever (massive intravascular haemolysis leading to haemoglobinuria)
Acute Renal Failure (usually acute tubular necrosis due to presence of sequestrated
infected red blood cells in the renal tubules and hypovolaemia).
Disseminated intravascular coagulopathy (DIC) due to consumptive coagulopathy;
Metabolic acidosis resulting from anaerobic tissue respiration, dehydration and renal
failure;
Hypoglycaemia due to starvation from anorexia, vomiting, and use of quinine and also
due to competition for serum glucose by malaria parasites.
Pulmonary Oedema due to sequestration of parasitized red blood cells in the lungs and
from heart failure and IV fluid overload.
156
Vivax and Ovale malaria may be associated with relapses. This is due to some of the
circulating parasites (merozoites) returning to the liver and remaining dormant until a
later date when the immunity wanes and re-seeding of the blood occurs.
TREATMENT OF MALARIA
A. Treatment of malaria in infants and children poses special problems because of
the following reasons:-
Acute attacks of malaria are more severe than in adults;
Vomiting is common and reduces the treatment options as oral medication may not be
possible;
Cerebral malaria is more common than in adults;
Gastrointestinal complication presenting with diarrhea and vomiting can cause severe
dehydration;
Anaemia may be severe enough to require blood transfusion;
Compliance with medications can be poor because children cannot be made to
understand its importance, therefore, parent' health education and their cooperation re
absolutely vital in the treatment of malaria.
Except in case of drug-resistance, quick acting schizonticides are more preferable than
slow acting ones in the treatment of acute attacks of malaria. Treatment of simple
versus complicated infection will be discussed separately thus:-
The recommended first line treatment for malaria treatment is Artemesinin – based
combination therapies (ACT). There are different ACT formulations in the market.
157
A combination of amodiaquine and sulfadoxine/pyrimethamine is also used in some
areas.
Oral quinine 10mg kg every eight hours should then be administered to make up to
seven days of quinine therapy. In addition to the correction of anaemia, hypoglycaemia,
water and electrolyte imbalance if they exist should be corrected.
OR
If facilities for iv drip are not available, give deep iv quinine 10mgs salt/kg before
referral.
158
For intramuscular quinine, the quinine should be diluted in normal saline to
concentration of 100mg salt/ml. The intramuscular site should be in the antero lateral
thigh region.
OR
Intramuscular Artesunate 2.4mg/kg loading dose, followed by iv. 1.2mg/kg at 12 and 24
hours, then 1.2mg/kg daily or 6 days.
OR
Intramuscular
Artemether 3.2mg/kg (loading dose) followed by 1.6 mg/kg daily for 6 days. When the
patient is able to swallow, the daily dose can be given orally.
Artemesinin Suppositories: 40mg/kg, loading dose intra rectally, then 20mg/kg given 24,
48, & 72 hours later, followed by oral first line drug.
RII drug resistance with low parasitaemia which never clear completely;
RIII drug resistance with persistently high parasitaemia for twenty-eight days.
There should be no re-infection and the drug given should be well tolerated. Clinically,
drug resistance should be suspected when there is:-
Persistence of fever and no improvement forty-eight hours after starting drug treatment;
Poor laboratory response to the antimalarial treatment when blood test is done daily as
treatment proceeds.
MALARIA CONTROL
The World Health Organization (WHO) has defined levels of malaria control
interventions (Tactical variants) with ultimate aim of malaria eradication. Malaria control
is also part of Primary Health Care since 1978.
Tactical Variant I
Aims at reducing and preventing both mortality and morbidity due to malaria using
antimalarial drugs. Essential drug programme should therefore be encouraged for
efficient distribution of antimalarial drugs to the acutely ill patients.
159
Tactical Variant II
Aims at reducing and preventing both mortality and morbidity due to malaria. This calls
for antimalarial drugs for both curative and chemo prophylaxes for the high risk
vulnerable groups with include:
The non-immune immigrants;
The pregnant women
Under-fives with special problems, e.g., sickle cell anaemia
Tactical Variant IV
Aims at achieving countrywide malaria control. It is concerned with surveillance after
malaria control has been achieved and ensures that resurgence does not occur. The
long term aim is eradication of malaria.
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IMMUNITY AND VACCINE DEVELOPMENT
Immunity to malaria parasites can be natural or acquired.
Natural Immunity
Genetic Immunity is seen in:
Some black communities due to some form of natural selection, e.g., Duffy blood
groups and P.vivax infection.
Population with long exposure to P.Falciparum is probably due to natural section.
Acquired Immunity
Immunity is due to stimulation of combined humoral and cellular (phagocytic) protective
mechanisms by previous infections. There is also transient acquired passive immunity
from the mother to child, mainly through the placenta and breast milk, but does not go
beyond six to nine months of age. The period between passive acquired and actively
acquired immunity to malaria accounts for the child's most dangerous malaria infections
in endemic areas.
Malaria antibodies in the blood neutralize the toxin of the parasite or interfere with its
multiplication. However, the immunity is strain specific. Acquired immunity of high
degree is associated with a high level of gamma-globulins in plasma, (IgG, IgM).
Vaccines
The mechanism for the protective role of antimalarial vaccine is poorly understood but
there is evidence that humoral (IgG and IgM), cell mediated responses (T-cells) and
non-specific responses (e.g., killer cells) are involved.
Efforts to produce useful vaccines to the malaria parasites are still in progress and there
are prospects that a broad-spectrum vaccine (which is effective against all antigens) will
be available before long.
SPF 66 - This is the malaria vaccine designed and produced by Prof. Manual Patarroyo
in Bogota, Colombia. SPF 66 is a synthetic peptide consisting of amino acid sequences
derived from three sexual stage proteins and derived from the circumsporozoite protein
of plasmodium falciparum.
This vaccine was initially received with skepticism after initial clinical testing showed
some success. Clinical tests done in Tanzania and the Gambia showed variable
results. The Tanzania study showed a clinical efficacy of 30-60%, while studies in the
Gambia, done in children under 1 year, showed no protection at all. However, this
study was one over a short period of time in a low malaria endemicity season.
161
REFERENCES
Jellife D.B. and Stanfield J.P. (eds) Malaria in: Diseases of Children in the Sub-tropics
and Tropics 3rd ed. The English Language Book Society and Edward Arnold
(Publishers) Limited 1982, 827 -856.
Wilcokes, C. and Manson-Bahr P.E.C (eds): Manson's Tropical Diseases. The English
Language Book /Society and Bailliere Tindal, London, 17th Edition, 1976: 39 -86.
Hendrickse R.G. Barr DGD, Mathews (eds) Malaria in: Paediatrics in the Tropics. 1st ed,
Blackwell scientific publications. 1991, 695-710.
Genton B, Smith T, Bae K, Narara A, et al, Malaria: how useful are clinical criteria for
improving the diagnosis in a highly endemic area, Trans Roy Soc Trop Med and Hyg.
(1994) 88, 537-541.
Cox M.J. Kun D.E., Tavul L, Narfara A, et al: Dynamics of malaria parasitaemia
associated with febrile illness in children from a rural area of Mandary, Papua New
Guinea. Trans Roy Soc Trop Med and Hyg. (1994) 88, 191-197.
Brenan J.G. Campbell C.C. Combating Severe Malaria in African Children. Bull WHO
66 (5) 1988) 611-620.
Greenwood A.M, Armstrong R.M. Byass P, Snow R.W., Greenwood B.M: Malaria
Chemoprophylaxis, Birth Weight and Child Survival Trans Roy Soc trop Med & Hyg.
(1992) 86, 483-485.
Payne D. Use and Limitation of Light Microscopy for Diagnosing Malaria at the Primary
health Care Level. Bull. WHO 1988 66 (5) 621-626.
Malaria Diagnosis: Memorandum from WHO meeting. Bull. WHO (1988) 66 (5) 575-
594.
Hendrickse R.G, Adeniyi A: Quartan Malarial Nephrotic Syndrome in Children. Kidney-
Int 1979 July, 16 (1); 64-74.
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CHAPTER 13
INTRODUCTION
The term AIDS stands for Acquired Immune deficiency Syndrome. The first case was
reported in 1981 in the US among men who have sex with men. Uganda was the first
African country to report a case of AIDS in 1982. Between 1982 and 1986, AIDS cases
were identified in many other eastern and southern African countries. Since then
HIV/AIDS has rapidly evolved into a global pandemic. UNAIDS estimated that by the
end of 2006 there were about 40 million people living with HIV/AIDS globally. Within
Sub-Saharan Africa (SSA), southern Africa is the worst affected region. HIV infection
has increases child mortality and essentially wiped the gains made in promotion of the
child survival packages.
OBJECTIVES
At the end of this chapter the student should be able to:
Learning activities
Visit an antenatal clinic and talk with staff on how mothers are counselled on being
tested for HIV
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Does a role play to mimic testing and counselling in a clinic
During your obstetric rotation make sure you participate in the care of a mother with HIV
infection
Participate in the care of an HIV infected child
Explore how the community cares for an HIV infected family
The magnitude of the problem is shown in table 1. Without intervention, 30-40% of HIV
infected women will transmit the infection to their babies. The risk of transmission is
highest in women with high viral loads and in those with advanced disease. Mother-to-
child transmission of HIV can take place during pregnancy, at the time of delivery and
during breastfeeding. The estimated absolute transmission risk without intervention as
follows: 10% during pregnancy, 10-20% during delivery, and 10-20% during
breastfeeding. With the use of antiretroviral drugs HIV transmission can be reduced to
as low as 1% in non-breastfeeding populations and to as low as 5-6% in breastfeeding
populations.
Without interventions HIV-1 infected children have a nine-fold increased risk of dying in
the first two years of life compared to non-infected children. If the mother dies,
regardless on the HIV infection status there is a 3-8 fold increased risk of death. The
ultimate goal for PMCT is to have HIV-free survival and therefore the strategies for
PMCT are geared towards preventing HIV transmission from mother-to-child and
promoting the survival of the mother and child.
There is evidence that sexually transmitted diseases (STDs) enhance the transmission
and acquisition of HIV. Recent evidence suggests that the key driver of the HIV
epidemic in Africa is the combination of the low prevalence of male circumcision and
high prevalence of multiple concurrent sex partner.
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MODES OF TRANSMISSION
There are three main modes of transmission:
More than 90% of paediatric HIV infections are acquired through mother to child route.
Contact with blood or blood products may result in HIV infection through use of
unsterilized syringes and instruments, scarifications and transfusion with contaminated
blood or blood products. Sexual exposure especially in adolescents, sexual abuse (rape
and defilement both male and female), early marriage, prostitution and multiple
concurrent sex partners all increase the risk of sexual acquisition of HIV.
The third pillar involves the care and support of the HIV-infected woman during
pregnancy and lactation. The three most effective interventions with respect to
preventing transmission are HIV testing, provision of effective antiretroviral prophylaxis
and treatment and modification of infant feeding. HIV testing should be offered routinely
to all pregnant women in the antenatal clinics and maternity. Antiretroviral prophylaxis
should start early (28 weeks or earlier) and consist of at least AZT with single dose NVP
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being used for those who present only in labour. At birth, all exposed infants should be
offered single dose NVP plus AZT for four weeks regardless of whether the mother
received prophylaxis. Mothers who meet treatment criteria should be commenced on
HAART as soon as possible. For further details refer to the latest WHO guidance on
antiretroviral drugs for treating pregnant women and preventing infection in infants.
Breastfed infant are at risk of HIV and this risk increases with the duration of
breastfeeding. Replacement feeding is the best way to prevent infection in such babies.
HAART in breastfeeding mothers significantly reduces the risk of transmission through
breastfeeding. When either HAART or replacement feeding are not possible, exclusive
breastfeeding offers the next best option for the survival of HIV exposed infants. Animal
proteins are required in complementary foods of non-breastfed babies in order to meet
their nutritional requirement.
The fourth pillar is to do with the survival of the family unit, that is, the mother, child and
other family members. For the woman this includes prevention and treatment of
opportunistic infections (co-trimoxazole and INH prophylaxis), psychosocial and
nutritional support, family planning and provisional ART if eligible. For the infant, the
essential package includes adequate nutrition, immunization, routine de-worming,
growth and development monitoring, treatment of acute infections, provision of
multivitamin and micronutrient supplementation, co-trimoxazole prophylaxis, early infant
diagnosis and provision of ART if eligible. For all other members of the family, HIV
testing and where appropriate OI prophylaxis and ART treatment should be instituted.
HIV is retrovirus of the lentiviridae group. Several retroviruses have been described as
infections of various animal species (goats, sheep, cats and non-human primates).
These viruses characteristically are immunosuppressive or oncogenic. These viruses
are called retroviruses because they have the ability to make a DNA template from a
RNA strand. Three retroviruses have been documented to cause disease in man.
HTLV-1 causes T-cell leukaemia and Tropical spinal paralysis while HIV-1 and HIV-2
cause AIDS.
The virus is made of a RNA core surrounded by a glycoprotein (gp) envelope that has
several important components - gp 160, gp 120 and gp 41 - that facilitate the
attachment of the virus to the target cells. The virus has a predilection to immune
competent cells that contain the CD4++ receptor such as T4 cell tissue macrophages,
dendritic cells in the brain and Langerhan’s cells. Once the virus enters the cells it
makes the DNA template which them attaches and integrates into the cell genome.
Thus the cell is infected for life.
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Figure 1: Structure of human immunodeficiency virus
HIV like other viruses is easily destroyed by boiling, steaming or direct sunlight. Due to
its lipid containing envelope pf, the virus can be destroyed by various chemicals such as
hypochlorite (household JIK), glutaldehyde and formaldehyde as well as alcohols,
acetone, phenols and several detergents.
HIV infected individuals develop antibodies initially to the envelope proteins and
eventually the core proteins. Detection of these antibodies is the basis of HIV ELISA
(enzyme linked immuno absorbent assay)
The HIV virus progressively destroys CD4+ cells until immune deficiency develops. The
natural disease course appears to follow two broad patterns in children – ‘rapid
progressors’ and ‘slow progressors’. Rapid progressors experience rapid progression
to AIDS and death within 6-24 months and this pattern tends to occur among children
infected in utero or around birth at a time when their immune system was very
immature. These children often present with an array of clinical characteristics including
wasting, pneumocystis carini (jiroveci) pneumonia, sepsis, hepatosplenomegaly and a
rapidly progressive CNS disease. Slow progressors tend to survive beyond 2 years, and
some may progress slowly beyond 5-10 years before developing AIDS. This tends to
be the course of disease among children infected after birth through breastfeeding, at a
time when their immune system was slightly more mature. Studies among African
children show about 50% of HIV infected children die before 2 years, 75% die by age 5
years, and only 25% survive beyond age 5 years. This mortality is higher than that seen
among HIV infected children in industrialised countries likely because the higher
prevalence of other causes of morbidity and mortality in the African setting – including
malnutrition, infectious diseases and poor access to health care. Therefore, early
diagnosis and appropriate treatment are critically important.
Infection with HIV-2 which is found more commonly in West Africa progresses much
more slowly than infection with HIV-1.
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THE DIAGNOSIS AND STAGING OF HIV IN CHILDREN
Laboratory testing
The mainstay of HIV diagnosis is the HIV ELISA antibody test. This assay is cheap and
relatively easy to perform. One can use a rapid test consisting of (a) Determine-
screening test (b) Stat Pak as a confirmatory test and (c) Unigold as a tie-breaker in
case of discordance. This is a reliable test and enables the patients to get their test
results within fifteen to twenty minutes. However, in young children (<18 months) whom
may have acquired HIV antibodies from their mothers, this method is not accurate. In
such children the more expensive but accurate DNA PCR is required to confirm the
diagnosis. This test removes the DNA (sometime RNA) from mononuclear cells and
amplifies sequences of genetic material which match the HIV virus and then tests for
the genetic material. It is currently the most accurate and sensitive method of
diagnosing HIV infection in young children. Although it is relatively expensive and
requires stringent laboratory conditions, costs have been declining and it is becoming
more widely accessible in developing country settings.
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CLINICAL STAGE I (ASYMPTOMATIC)
Asymptomatic
Persistent generalized lymphadenopathy
CLINICAL STAGE II (MILD)
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Fungal nail infections
Angular chelitis
Lineal gingival erythema
Extensive skin warts (papilloma virus or molluscum contagiosum)
Recurrent oral ulcers
Unexplained persistent parotid enlargement
Herpes zoster
Recurrent or chronic upper respiratory tract infections
(otitis media, otorrhoea, sinusitis, tonsilitis)
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Kaposi's sarcoma
Oesophageal candidiasis (or candida of trachea, bronchi or lungs)
Cytomegalovirus infection; retinitis or CMV infection affecting another organ, with
onset after
age 1 month
Central nervous system toxoplasmosis (including meningitis)
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
Chronic cryptosporidiosis (with diarrhoea)
Chronic isosoporiasis
Disseminated non-tuberculous mycobacteria infection
Cerebral or B cell non-Hodgkin lymphoma
HIV encephalopathy
Progressive multifocal leukoencephalopathy
HIV-associated cardiomyopathy or nephropathy
Immunologic Staging
To identify children needing immediate ART the WHO has developed a system of
classifying the level of immune deficiency for HIV infected children using their absolute
CD4+ count or CD4+ percentage (Table 3).
CD4+% = (absolute CD4+ count per mm3/ total lymphocyte count per mm3) x 100.
Children with absolute CD4+ count or with CD4+% below that indicated in the table 3
are defined as having severe immuno-deficiency (severely immuno-suppressed).
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MANAGEMENT OF HIV AND ITS COMPLICATION
Co-trimoxazole therapy
Prophylaxis against PCP especially in infants is associated with reduced mortality. All
infants should be started on prophylaxis until they are proven to be uninfected.
Generally this is started at six weeks to coincide with the first immunization.
The goal of Antiretroviral Therapy is to improve the quality of life and ensure normal
growth and development through the following:
Binding, fusion
and entry
Viral protease
RNA RNA
Proteins
Reverse RT
transcriptase
RNA
RNA
DNA
RT
DNA
DNA Provirus
Viral integrase
Several classes of antiretroviral drugs are currently in use (Table 4). However, some of
the newer classes of drugs may not be widely available. Commonly used ARVs in
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resource restricted countries include reverse transcriptase inhibitors, non-nucleoside
reverse transcriptase inhibitors and protease inhibitors.
Reverse Transcriptase Inhibitors (RTIs) inhibit the viral reverse transcriptase enzyme
(RT) thus preventing the virus from making DNA copies of its own RNA, an essential
step in viral replication. They include zidovudine (AZT), lamivudine (3TC), abacavir
(ABC) didanosine (ddI) and stavudine (d4T). Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTIs) bind directly to the RT enzyme thereby blocking its activity. They
include nevirapine (NVP) and efavirenz (EFV). Protease Inhibitors (PIs) inhibit the
protease enzyme thereby preventing protein cleavage and assembly in the last stages
of new virus production in the CD4+ cell. This class of drug is usually reserved for
second line ARV regimens. PIs include ritonavir, lopinavir, nelfinavir and indinavir.
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Table 5: Criteria to Start ART in Children
Age Infants < 12 – 35 36 – 59 5 years and
12 months months months over
CD4+ % All infants < 25% < 20% < 15%
Absolute CD4+ require < 750 < 500 < 350
Count ART
WHO Clinical Stage 3 or 4 3 or 4 3 or 4
Counselling Preparation:
Counsel the parent/guardian on the following: Up to three adherence counselling
sessions may be necessary, however, if the caregiver has another child or she/he
herself/himself on ARVs this may not be necessary. Caregivers must be counselled on
when and how to administer the drugs, possible adverse effects of the drugs and how to
recognize them, and should be encouraged to bring the child on treatment back to clinic
if they have concerns or if the child becomes ill. Care should be taken not to overload
caregivers in one session as successful counselling is a continuing process and not an
event.
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Immune Reconstitution Inflammatory Syndrome
Within weeks of starting HAART some patients may develop an acute inflammatory
syndrome that can be quite debilitating. These are severely immune depressed patients
in whom CD4+ cell recovery occurs rapidly. The ensuing inflammatory process as the
immune system responds to previously quiescent infection (e.g. TB or PCP) is called
immune reconstitution inflammatory syndrome (IRIS). Management of IRIS includes
identifying the underlying disease process and use of steroids may be required to
control symptoms. Patients developing IRIS or IRIS-like symptoms should be referred
for specialist care.
Creatinine + + Every 12
months
CD4+ + (+) + Every 6-
12
months
Viral load (+) (+) (+) Every 6-
(HIV PCR)*** 12
months
Lipid profile, + + + Every 6
fasting blood months
sugar****
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*
FBC = full blood count; ** LFT = liver function tests. Minimum, assay serum alanine
transaminase (ALT or SGPT); *** RNA PCR for viral load; ****For children on protease
inhibitors; ( ) Parenthesis indicates test is optional, perform if affordable or if deemed
necessary.
At each visit:
Plot the physical growth of the child on growth chart.
Address ongoing medical problems; treat any intercurrent infections, if present.
Give co-trimoxazole prophylaxis and
Provide nutritional supplements (such as multivitamins)
Carry out and record an objective assessment of adherence.
The most important determinant of treatment success is adherence. Greater than 95%
adherence is necessary for optimal therapy that is one that ensures complete viral
suppression and maximal durability of the first line regimen. If a child misses more than
1 dose in ten days it implies < 95% (suboptimal) adherence, and health-worker should
counsel parent to identify causes of missed doses ways to address them immediately.
Peer clubs
Parents’ support groups
Organized outings e.g. Camp
Drama clubs
Classes for caregivers.
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CHAPTER 14
INTRODUCTION
Anaemia is defined as a reduction in haemoglobin level or oxygen carrying capacity or
blood below the level that is expected for age and sex. It is a world wide health problem
but especially in the developing countries. It is a common disorder in childhood where it
causes mobility and mortality. In an individual child with anaemia, there are usually
multiple causative factors.
Define anaemia
Describe the variation of haemoglobin level by age
Describe the morphological classification of anaemia.
Describe the various causes of anaemia
Describe the clinical tubes of anaemia
Describe the clinical features of anaemia
Describe the laboratory investigations for an anaemic child
LEARNING EXPERIENCE
Practice the examining a child with anaemia in the clinic.
Participate in the planning for investigation of a child with anaemia.
Check on treatment chart how a child with anaemia is managed while on the ward at the
hospital.
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Red cell morphological types of anaemia
Microcytic Anaemia
In this group the red cells are smaller in size than normal. This occurs in iron deficiency
anaemia, thallasaemia and lead poisoning. The red cells in these diseases are pale,
being less filled with haemoglobin (hypochromic)
Normocytic Anaemia
In this group, the red cells are normal is size and are usually filled with haemoglobin
thus referred to as normochromic.
This occurs in Malaria anaemia acute blood loss anaemia. The cells in haemolytic
anaemias ( sickle cells anaemia) are in this category.
Macrocytic Anaemia
In this group, the average red cells are larger than normal. This occurs in folic acid
deficiency and in B12 deficiency.
Age Hb gm/dl
6 months to 4 years 11
5 years to 11 years 11.5
12-14 years 12
Apart from this quantitative change in haemoglobin, there is a qualitative change in the
haemoglobin. At birth, the majority (50-95%) of haemoglobin is foetal haemoglobin with
only a small portion being adult haemoglobin. The foetal haemoglobin decreases rapidly
in inverse proportion to adult haemoglobin, so that by one year of age, only a small
amount of foetal haemoglobin is still present with majority being adult haemoglobin.
The specific causes of anaemia vary with the age of the child. In the newborn period for
example, anaemia occurs due to blood loss from umbilicus or bleeding from the
placenta during labour or as a part of ante-partum haemorrhage. In identical twins foeto-
foetal transfusion causes anaemia in one and plethora in the other twin. Anaemia also
results from haemolytic disease of the newborn, and haemorrhagic disease of the
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newborn. In infancy on the other hand, anaemia is commonly caused by malaria, blood
loss and dietary iron deficiency. Aplastic bone marrow may also cause anaemia in this
period. Sickle cell anaemia which is prominent later can also cause anaemia in infancy.
In childhood, the major causes of anaemia are malaria, sickle cell anaemia and chronic
blood loss like hookworm anaemia, and dietary iron deficiency as in case of lack of
dietary iron or folic acid. Several other factors like infections, renal disease, leukaemias
can cause anaemia in this age group.
Iron Metabolism: The foetus acquires its iron from the mother across the placenta.
This transplacental transfer of iron from the mother to the foetus is negligible during the
first and second trimester of pregnancy but it increases tremendously during the third
trimester. A foetus born prematurely does not have this benefit of acquiring the peak
transfer of iron. Foetal iron stores are 75mg/kg body weight both in the preterm and full
term infant but the preterm infant does not have large amount of total iron. A full term
infant born to a non-anaemic mother receives sufficient iron during foetal life to maintain
its needs for at least 3-4 months of infancy. The majority, seventy per cent, of the
neonatal iron stores is in the form of haemoglobin in the cells. The bulk of the remainder
is in storage form in the liver and other reticuloendothelial tissues. The other forms of
iron are myohaemoglobin, cytochromes, catalases and other iron containing enzymes.
Several factors occurring during pregnancy, childbirth and early neonatal period
contribute to the development of iron deficiency anaemia. In extreme maternal iron
deficiency anaemia, as occurs commonly in many tropical countries, the foetus acting
like a successful parasite has normal haemoglobin at birth, but runs short of iron stores
and develops iron deficiency anaemia in early infancy. Preterm infants out strip their
iron requirements when they grow rapidly since they have inadequate iron stores. Early
clumping of the umbilical cord denies the neonate blood which is in the placenta which if
allowed to be transfused into the baby, contributes so much haemoglobin. Early
clumping therefore predisposes to the development of iron deficiency. Blood loss from
the placenta in APH or from the cord at any time. or during foeto-foetal transfusion
causes iron deficiency. Generally, the following factors contribute to iron deficiency in
the preterm low birth weight infants:-
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the amount of iron in the diet, the nature of the dietary iron, presence of phosphates and
phytic acid, presence of ascorbic and hydrochloric acid and the iron status of the body.
Cow’s milk has little iron but in human milk is also low in content but is of high bio-
availability and most of it is extracted and absorbed by the infant. Dietary iron is
absorbed in the upper jejunum. Inorganic (ferric iron), is changed to ferrous iron which is
then absorbed. Ferric iron is not absorbable. Hydrochloric acid and ascorbic acid
enhance iron absorption whereas phytic acids in cereals and phosphates inhibit iron
absorption. Iron containing haem compounds (Meat) is split from the protein complex to
globin and is absorbed directly. DMT-1 (divalent metal transporter) is involved in
transfer of iron from the lumen of the gut across the enterocyte microvilli. While
hepcidine, a regulator of intestinal iron absorption allows iron to enter portal plasma.
Low hepcidine levels in iron deficiency increases this process. After absorption through
gut mucosa, the iron is carried across the mucosal membrane and is carried by iron
binding protein to the liver and other reticuloendothelial tissues where it is stored or to
the bone marrow where it is utilized to form haemoglobin of red cells. There is a
mucosal block which controls absorption of iron. Approximately two-thirds of stored iron
is in the form of ferritin. The other stored iron is in the form of haemosiderin.
In childhood, the causes of iron deficiency, in addition to those mentioned in the infants,
are inadequate iron intake, hookworm infestation and malabsorption. Iron deficiency
occurs when there is absolute low dietary intake as when the infants and children are
not given iron rich food like cereals, green leafy vegetable or meats. Food may be
rendered deficient of iron through fault preparation as in overcooking of the green
vegetable. Infants who are on prolonged milk are not receiving a diet with good source
of iron. The other causation factor of iron deficiency anaemia is hookworm infestation
which is discussed elsewhere but suffice it to say that the severity of this type of
anaemia depends upon: worm load, age of the child, type of hookworm parasite and the
dietary iron intake. Ancylostoma duodenale sucks more blood than Nector americanus.
An adult Nector americanus sucks on average 0.15 -0.2ML of blood per day while
Ancylostoma duodenale sucks 0.05ML per day. The worm sucks the blood as it feeds. It
then wonders off to another site leaving the old site bleeding. Iron deficiency anaemia is
often complicated by other deficiencies such as PCM, pyridoxine, folic acid and nicotinic
acid. In such anaemia, response will not occur to administration of iron therapy alone
without correction of the other deficiencies at the same time.
Clinical Features: Iron deficiency anaemia occurs at any age and is most common in
infancy and pre-school children: 2-5 years of age. As the development of anaemia is
usually gradual, the children tolerate it well without development of symptoms. Such
patients are encountered on routine physical examination without symptoms
whatsoever. Children with severe iron deficiency anaemia, with haemoglobin levels of 3-
5gm% may walk into clinics without signs of decompensation and anaemia may be
discovered as an incidental finding, while the child is attending the clinic for some other
illness. Often, the children come to hospital for other illness like pneumonia which
precipitate cardiac decompensation.
The symptoms of iron deficiency anaemia are pallor, irritability, lethargy, lack of vigour,
easy tiring on physical activities, poor appetite, poor attention spurn, lack of alertness,
increased tendency to pyogenic infections and pica or eating soil.
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Clinical examination reveals a pale child, with pale skin, mucous membrane, sclera,
palms and soles of the feet and nail beds. There may be brittleness of the nails with
spooning of the nails, koilonychia. There may be history of melaena, dark stools
containing altered blood due to chronic bleeding from the gut. In severe anaemia, there
may be signs of cardiac decompensation, and heart failure such as tachycardia,
breathlessness, palpitation, cardiac enlargement, raised jugular venous pressure shown
by engorged neck veins and oedema of the feet or face. There is also gallop rhythm and
heart murmurs.
Confirmatory tests are rarely done. They include determination of serum iron, and total
iron binding capacity (TIBC) also known as transferring. Serum iron is low; normal
values are 120, but in iron deficiency levels of 10-60ug are found. Transferrin is
normally 450ug but this is usually a third, 150. Iron saturation is usually 32 percent but
in iron deficiency it is about10 percent. Bone marrow shows reduced or no
haemosiderin, serum ferritin is reduced to below l0ug/litre.
Differential Diagnosis: There are a few conditions from which iron deficiency anaemia
should be distinguished. There are Thalassaemia minor and lead poisoning in which
microcytic hypochromic cells occur. A good history and physical findings would provide
assistance. In thalassaemia, there is a family history of the disease. The family has
relationship with Mediterranean people and the spleen and liver are enlarged. In chronic
lead poisoning, there is history of lead in the community particularly old lead paint.
Fortunately, lead paint is no longer manufactured.
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replenish iron stores in the tissues. The difficulty is ensuring that the medicine will be
taken while the child is at home. Administration of oral iron is followed by reticulocyte
response. The reticulocyte count which is initially low, increase in number and the
haemoglobin eventually rises. The patients with low haemoglobin have more rapid
response than those with higher levels. Lack of response by increase in reticulocyte
response or a rise in haemoglobin means a number of things:
Patients with malnutrition (PCM) will not respond to iron therapy alone without an
increased intake of protein. Administration of folic acid improves the response to iron
therapy as folic acid deficiency often coexists with iron deficiency. A quicker and a much
more effective way of correcting haemoglobin and replenishing iron stores is the
administration of parenteral iron such as iron dextran (Imferon) or iron sorbital. These
are indicated where there is severe anaemia or where the patient is not tolerating oral
iron. Parenteral iron can be calculated and given either as infusion or intramuscularly in
multiple sites. Where anaemia is very severe or life threatening, blood transfusion is
indicated to relieve hypoxia and save life. Care should be taken in giving blood
transfusion. As chronic hypoxia leads to weakened heart muscle, rapid blood
transfusion expands the plasma volume which the flabby cardiac muscles cannot cope
with, resulting in precipitated heart failure. To avoid such a calamity, several precautions
are taken namely:-
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ANAEMIA DUE TO MALARIA
Anaemia of malaria is one of the three common causes of anaemia in tropical Africa.
The other two being iron deficiency and sickle cell anaemia. Red cells which are
parasitized by malaria parasites haemolyze easily as the parasites bust out on their
maturity. Cells which are parasitized are also trapped and destroyed in the
reticuloendothelial tissue, mainly in the spleen, bone marrow and liver. Plasmodium
falciparum attacks both young and old red cells while the other species of malaria
parasites, tend to parasitize the older red cells only. The resulting anaemia is therefore
much more severe in falciparum infection than in the other species of malaria parasites.
Peripheral blood smears show Parasitized red cells, polychromasia, anisocytosis,
poikilocytosis and target cells. The red cells are normochromic, normocytic.
Clinically, the patient has anaemia and the features of malaria namely fever, diarrhea
and vomiting, weakness, enlarged spleen anorexia and failure to thrive. The anorexia
may lead to dietary deficiency. Haemolysis depresses the bone marrow complicating
the picture of anaemia. Malaria parasitaemia may also depress bone marrow
temporarily. The treatment of anaemia of malaria focusses on both anaemia and,
malaria. Artemisin is given for malaria. When anaemia is severe, blood transfusion is
necessary and life saving. Blood transfusion is recommended at dosage of 10ml/kg.
Iron therapy is not useful unless there is concomitant iron deficiency anaemia.
Sickle cell anaemia results from a genetic disorder in the formation of haemoglobin.
Instead of the normal adult haemoglobin, these patients have abnormal haemoglobin in
their red cells. This abnormal haemoglobin crystallizes out whenever there is lowered
oxygen tension as occurs in pneumonia. The red cells with crystallized haemoglobin
become deformed in sickled cells which are picked up and haemolysed in
reticuloendothelial tissue giving rise to jaundice and anaemia.
The many the sickle red blood cells are destroyed by haemolysis, the severe is the
resulting anaemia. Much haemolysis occurs during attacks called crises. The more
frequent the crises occur, the more severe is the resulting anaemia, which is often
brought about by infections such as malaria and pneumonia. Exposure to cold during
cold season also precipitate a crisis.
Clinical Features
The child with sickle cell anaemia will have other clinical features of sickle cells disease
such as hand foot syndrome (swollen tender hand, finger feet and toes) these occur in
early infancy. The child will have abdominal pain and distension. The distension is due
to enlarged spleen and sometimes also enlarged liver. As they grow they also get pain
in the limbs and back.
The features for sickle cell anaemia will include; pallor of hand and soles of the feet and
nail beds, pale mucous membrane and pale conjunctiva. The sclera, and mucous
membranes, the soles of the feet and palms will be jaundiced. Patients with sickle cell
anaemia will in addition have cardiac enlargement with heart murmurs.
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Laboratory Investigation
Haemoglobin level is low usually about 7gmldl. The red cells are normocytic and
normochromic. Sickling test is positive. Haemoglobin electrophoresis shows
haemoglobin SS instead of the normal hemoglobin AA.
Management
Throughout life the child with sickle cell anaemia should receive malaria prophylaxis to
avert malaria infection precipitating sickle cell crisis. The patient should be given daily
folic acid to replace folate last from the blood during sickle cell crises. Folic acid is
needed in the blood for the development of red blood cells otherwise megaloblastic
anaemia will develop as the body runs short of folic acid for normal synthesis of red
blood cells. Folic acid supplements is given orally in the dose of 2.5mg daily for children
below 5 years of age while those above 5 years of age receive 5mg daily. Iron should
not be administered to anaemic sickle cell patients. Normally the iron is stored in the
body following sickle cell crisis. Any additional iron is likely to cause iron poisoning.
Severe anaemia is management by blood transfusion.
Megaloblastic Anaemia
Megaloblastic anaemia is uncommon in tropical countries. When it occurs, it occurs on
infants early childhood in the form of folic acid deficiency and rarely due to B12
deficiency.
Vitamin B12 deficiency results from (i) inadequate intake (ii) lack of secretion of intrinsic
factor by the stomach (iii) lack of adequate consumption in inhibition of the B12 –
intrinsic factor complex of (v) abnormalities involving the receptor sites in the terminal
item. Vitamin B12 is present in many foods, dietary deficiency is rare. If may be seen in
extreme dietary restriction. Since vitamin bi2 is so common, the cases of vitamin biz are
normally due to failure to absorb the vitamin. Both folic acid and vitamin B12 deficiency
share some clinical features of anaemia with other deficiencies like iron deficiency.
Besides this, the affected infants with folic acid deficiency are irritable and have chronic
diarrhoea and stunted growth.
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Laboratory features apart from the general low haemoglobin level include typical
megaloblasts and giant metamyelocytes and hypersegmented megakaryocytes.
Megaloblastic anaemia responds to folic acid administration in the daily dose of 5mg
daily for 2-3 weeks. Folic acid should be administered together with ascorbic acid. As
folic acid is the more common cause of megaloblastic anaemia, it should be given
alone. Dietary deficiencies of folic acid if considered should be corrected by giving
green vegetables proteins , liver and kidney which are rich in folic acid.
Aplastic Anaemia
Aplastic anaemia is a rare form of anaemia. It is caused by bone marrow failure. Where
bone marrow fail to produce. Red blood cells as well as white blood cells and the
platelets. This result in pancytopenia. It may be congenital or acquired. The acquired
form is sub divided into; idiopathic and secondary aplastic anaemia,. The idiopathic type
forms the majority of the cases being responsible for about 50% of the cases and has
no known aetiology. The congenital form of aplastic anaemia is also known as Fanconi's
anaemia and is associated multiple congenital defects involving the skeletal system,
skin, kidneys and the chromosomes. The skeletal defect includes: hypoplastic or absent
thumb and thenar eminence, absent radius, syndactyly and abnormalities of the long
bone. There are skin lesion such as hypopigmented spots and patches of pigmentation.
There may also be ptosis of the eyelids, abnormal ears and mental retardation.
The secondary form of aplastic anaemia results from a variety of insulting environmental
factors.
The incidence of aplastic anaemic vary according to the presence of the causative
factors.
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cells and red blood cells are very low. Bone marrow trephine instead of bone marrow
aspiration is done and this helps in assessing cellularity of the bone marrow. From
these clinical and laboratory features together with history of exposure to toxic
substances drugs, infection and irradiation confirms the diagnosis.
Management of aplastic anaemia is fraught with difficulties. The main stay of treatment
is repeated blood transfusion. Unfortunately repeated blood transfusion may lead to
development of antibodies to blood making it difficult to continue with blood transfusion.
Repeated blood transfusion may lead to yet second problem that of haemosiderosis.
This can be anticipated and avoided by administration of desferrioxamine an iron
chelating agent administered during the course of blood transfusion. This chelates iron
from the tissues testosterone administration may stimulate red cell production leading to
a possible emission.
routine administration of antibiotics as a prophylaxis for infection can also be tried but is
safer to detect infection early and institute effective antibiotic treatment.
REFERENCE:
Eicholzer M, Tonz O and Zimmerman R Folic acid: a Public Health Challenge Lancet
367:1352, 2006
Wang RH, Li C, Xux et all -A role of SONA D4 in iron metabolism through the positive
regulation of hepcidine expression Cell Met 2:399, 2005
185
CHAPTER 15
INTRODUCTION
In many developing countries adolescents have not had special services made
available to them. Problems such as adolescent pregnancies, STIs, early marriages,
child labour, child prostitution, civil strife creating orphans, destitute children and the
generally unfavorable economic conditions, have all contributed to the deterioration in
the health status of adolescents; hence the need for separate adolescent health care
services. This has become even more critical because of the current HIV/AIDS
epidemic that is affecting mostly adolescents, especially girls.
The definition of an adolescent varies in terms of age limits, from one organization to
the other. The definition adopted in this book is that by the World health organization
which is: A person aged 10 – 19 years. The adolescent period can further be sub-
divided to:
Early adolescents (10 to 13 years,
Mid Adolescent (13 to 15 years)
Late adolescents (16 to 19 years).
Characterizing adolescents this way helps pick out the unique psychological issues that
are faced by different groups
The issue here is not so much the age definition of the adolescent but rather the fact
that SSS is characterized by a very young population with 50% of the population in
many countries being below 20 years of age. In 1990, 31% of Africa’s population was
between the ages of 10-24 years. This makes adolescents a large part of the general
population in any country in the SSA region. The health of the adolescent is therefore
very important in determining the future general and reproductive health of the
populations in the region. In SSA, the health problems of the adolescent population are
very similar. This chapter therefore discusses the major adolescent health needs, their
health problems, approaches towards, their management and the organization of
services that can adequately respond to their health needs, especially in SSA.
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Learning objectives
At the end of this chapter the student should be able to:
Learning Activities
To facilitate learning, students will be exposed to and participate in activities targeted to
adolescents in the community in both rural and urban settings. These will include:
Many factors such as early puberty breakdown of tradition norms and values, foreign
influence through television and media, economic hardships, urbanization and schooling
have led to more and more liberal attitudes and practices by adolescent leading them to
initiate sexual activity at an early age with about 80% of adolescents having their first
sexual intercourse by 19 years of age. Recent unpublished survey results from the rural
areas in East, Central and Southern, Africa have shown that 75% of girls interviewed
had their first sexual experience before the age of 16 years. Most of the sexual
intercourse was unprotected and could have led to infection with an STD or to
pregnancy.
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Adolescent pregnancy and fertility
Teenage pregnancies contribute up to one third of all pregnancies in Africa South of the
Sahara. In East Africa they contribute to about 20-30% of all pregnancies occurring in
women aged 15 to 49 years while adolescents comprise 35% of all obstetric cases. It is
well known that teenage pregnancies have a higher incidence of complications and
maternal mortality. The DHS in the region have shown that adolescents contribute
about 11.5% of all births in Eastern and southern Africa suggesting that a large
proportion of adolescent pregnancies end up as abortions. Furthermore 81% of all girls
aged 15 to 19 years interviewed in Rural Kenya had at least one pregnancy. In addition
to the health risk that the adolescent pregnancy poses, such unplanned pregnancies
lead to high school drop-outs with loss of career opportunities and severe psychological
and social consequences.
Few countries have liberalized contraceptive use for adolescents. Among these are
Botswana and Seychelles. Even in these countries adolescent contraceptive use is very
low. The reasons for this state of affairs is the negative perception that contraception
use is associated with multiple partners in the case of married couples and increased
sexual activity among the youth. In a four country study involving Tanzania, Seychelles,
Uganda and Zimbabwe undertaken by the Commonwealth Regional Community
Secretariat, results showed that whereas the contraceptive knowledge was as high as
80% among adolescents, use was as low as 5%. Similar results are available from the
DHS studies.
Preventive actions:
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Promoting knowledge and attitudes that prevent the need for abortion through sexual
abstinence, contraception
Early Marriage
Many societies in SSA have cultural practices that encourage marriage of girls in early
adolescence. This is associated with fertility, reduced educational opportunities for the
affected, and health complications such as premature delivery, toxemia of pregnancy,
anemia obstructed labour, Vesico-vaginal fistulae (VVF) and various forms of injuries to
the birth canal. This is of particular importance in the rural areas where early marriage is
commonest and access to health care is least.
Preventive action
Advocacy for protection of children’s and adolescent’s rights for education and career
development and in prevention of their sexual exploitation
Advocate for change of cultures and subcultures that practice early marriage
Unprotected sex as is the practice among adolescents is associated with high incidence
of STIs. It is also true that adolescents are more biologically vulnerable to STIs due to
their immature physical development. In addition to these, economic forces that lead
adolescents to accept being used sexually for financial favors and often ending up in
prostitution all further exacerbate the likelihood of contracting an STI or HIV infection.
They are also misinformed about STIs and AIDS and thus unprepared to take
appropriate preventive action. An estimated 36% of women aged 15-24 had an STI. The
incidence of STIs and HIV infection are rising at a very high rate in the region. Public
awareness and practical preventive approaches must be developed and implemented.
These interventions must involve adolescents themselves. There is evidence that
aggressive treatment of STIs especially gonorrhea and genital ulcer disease is
associated with a 42% reduction in the incidence of HIV infection. This is an important
finding that must be made use of. Following increase of ARVs and PMTCT there is an
increasing number of children who acquired HIV infection perinatally and are now
reaching adolescence. This particular group of HIV infected children will sex education,
peer group support and readily available counseling services.
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Management
Formal and informal education on the mechanisms of transmission of STDs and HIV
infection. School curricula must have adequate content in this regard. Similarly,
teachers must be educated on mechanisms of transmission of the common STDs, and
HIV and preventive activities, as they are an important source of information for the
adolescent.
Provision of special health service facilities that the adolescents are comfortable to use.
These should have diagnostic facilities, treatment and counseling.
Services for the diagnoses and treatment of STDs should be decentralized to the health
centre level to ensure easier access to the majority of the population.
Adolescents like to experiment and take risks including using illicit drugs and alcohol.
The problem of drug and substance abuse in Africa has reached alarming proportions
although accurate data is not available. The drugs abused range from alcohol, tobacco,
various stimulants and the more addictive forms such as cannabis sativa, etc. Addiction
to drugs for the adolescent is often the end of the road in as far as education and career
development are concerned. Various factors have been blamed for drug and substance
abuse among adolescents. These include being idle, poverty, lack recreation during
leisure time, peer pressure, unemployment, lack of guidance and inadequate family
support.
Preventive actions
Put in place national policies that expressly prohibits drug trafficking and use,
accompanied by appropriate penalties and other preventive legal actions.
Undertake public education and create awareness on the dangers of drug abuse to the
society and the individual.
Develop treatment, counseling and support systems in the communities for individuals
diagnosed to be drug dependent.
Involve youth groups in programmes aims at the control of drug abuse.
Create community recreation centres
Encourage students in schools to join social and academic clubs and ensure presence
of such clubs in all schools in the country
Encourage and support peer education to improve adolescent health
It is recognized that peer education is a powerful tool to improve adolescent health.
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Special Problems of the Pre-adolescent Child:
Current state of inadequate education in reproduction, sexuality and life skills essentially
allows them to enter adolescence without any preparation. This predisposes them
sexually transmitted diseases, and unwanted pregnancies. Pre-adolescent children
need at least minimum information regarding their own reproductive potentialities and
the problems associated with risky sexual behaviour.
In addition to health care provision to students, the education system should ensure
that curricula contain adequate health promotion and disease prevention topics. It is
accepted that the commonest source of most health information to school children in
this age group is the teacher. This is particularly true of reproductive biology and
sexuality. It is equally true that the primary school teacher has often not been prepared
enough to take up this task. There is urgent need to address this matter.
Under this category falls the street children, orphans, mentally and physically disabled.
Over the last decade more than ever before there had developed a large population of
orphans due AIDS, civil strife, road traffic accidents etc; poor obstetric care leading to
birth asphyxia or other injury and adolescent pregnancy leading to abandoned children.
These are growing problems and not enough is being done for these groups. Special
programmes to identify them early and provide them with the necessary support
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Intervention matrix to improve some aspects of teenage Reproductive Health
Objective IEC content Activity Materials
To raise Concept of family Discussions, Leaflets on puberty,
awareness on Puberty in boys lectures, diagrams of
reproductive and girls demonstrations, reproductive organs,
potential Emotional role plays, films on puberty
changes towards simulations,
opposite sex observations,
reading
To educate on Gonorrhea, Discussions, Leaflets on STDs
endemic STDs in syphilis, lectures,
the study area HIV/AIDS, demonstrations,
chancroid, pubic role plays,
lice, simulations,
observations,
reading
To enable youths HIV/AIDS Discussions Films on AIDS
educate others on transmission and
HIV/AIDS the disease
process
To educate on Dangers to the Group discussions Leaflets
dangers of individual the on dangers and
HIV/AIDS to youth family and the honesty about AIDS
nation
To enable youths Sex in and out of Group discussions, Condoms
avoid HIV and marriage, tips on role plays, condom
other STDs choosing a use, demonstrations
spouse, saying no
as a contraceptive
To enable youths Where to get Discussions, tour of The Youth Centre
get counseling on services, and youth centres
STDs description of
what happens
during counselling
To enable youths Ovulation, Discussions and Leaflets, posters,
describe ejaculation, demonstrations and reference books
conception, conception,
pregnancy and pregnancy, MCH
childbirth services, men and
MCH services
To enable youths Responsible Discussions, tour of Physical address of
learn tips of parenthood, FP youth centres youth center,
responsible services, FP leaflets, films
parenthood counseling
To enable youths Problems e.g. Discussions, Posters, leaflets,
describe problems injury, distribution of films
of teenage complication, leaflets and posters
childbearing responsibilities
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Priority Research Needs in adolescents
The field of adolescent health remains an elusive one. Little is known about factors that
determine the behaviour of adolescents and therefore what would be the best strategies
to adopt for various interventions. Operations research is therefore needed to
determine.
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CHAPTER 16
INTRODUCTION
Accidents and poisoning are important causes of childhood morbidity and mortality
worldwide. Mortality is highest in the one to five year age group. Primary health care
workers need to be familiar with the common types of accidents and poisoning in their
own environment in order to be able to plan interventions and curative services as well
as setting strategies for prevention.
OBJECTIVES
At the end of this chapter, you should be able to:
LEARNING ACTIVITIES
Spend time in the casualty department of your hospital and count the number of child
accident victims.
Participate in the management of an injured child.
Visit the burns unit in your hospital and observe the management of a child with burns.
Clerk a child with poisoning.
Visit the toxicology department in your area and discuss common types of poisoning
encountered
Visit a nearby zoo and learn about poisonous snakes.
Case illustration
Kamau aged four years and Otieno aged two years were well when their mother left
them asleep in the afternoon. The mother did not have a domestic helper so she locked
the children in the house. Two hours later when she came back she found her two
children unconscious on the floor. Clutched in the hands and scattered on the floor were
sugar coated aspirin tablets used by an older sibling with rheumatoid arthritis. The
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mother rushed both children to the local General Hospital. One hour later, both children
were breathing fast, running a fever and convulsing.
Question 1 What are the metabolic derangements that led to fever, fast breathing,
convulsions and coma in these children?
The doctor on call started treatment on both children. He carried out some
investigations and decided to refer the children to a tertiary care health facility.
Question 5 What therapy was the referring doctor hoping that these children would
receive?
Question 6 How would you prevent a similar occurrence in this family and your
community?
The secretaries during both discussions should be prepared to report back to the class
in a plenary.
The facilitator should move from group to group, observing the group dynamics and
generally be available for any questions and clarifications.
1. Developmental stage
Accidents and poisoning are commonest in the toddler aged 9 months to the child aged
five years with a peak incidence in the age group of one to two years. At this age the
children are at a developmental age that is characterized by:
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2. Gender
Although accidents and accidental poisoning are reported to occur more frequently in
boys, two Kenyan studies found an equal distribution in both boys and girls.
3. Child-caring practices
Lack of adequate supervision is probably the single most important contributor to
poisoning. In many rural and urban areas, young children are left in the care of young
siblings. Children aged 3 years or more are increasingly attending school and thus the
older children are not available to assist the mother with babysitting. A disturbing
pattern of child rearing is emerging where children less than three years of age are
sometimes left at home on their own, as mothers go to the garden or to the market. The
collapse of the extended family structure has led to limited options of alternative child
caring arrangements.
4. Poverty
Young children living in socio-economically deprived environments especially peri-urban
slums are at greater risk of accidents and accidental poisoning. This is because many
families now live in single room houses. As a result it is difficult to find a safe place to
store drugs and other poisonous agents, or even to be able to prevent exposure to
burns and scalds. The risk is further increased when both parents are either under
mental stress or are working away from home leaving the children under inadequate
supervision.
ACCIDENTS
Accidents can occur at any age as the child or adolescent interacts with his/her
environment. In developed countries, accidents are the leading causes of death in
children over the age of one year. In adolescents, alcohol and drug abuse contribute to
road traffic accidents.
The type of accident is determined by the child’s environment and gender. Among
school age children girls are most likely to experience burns and scalds in the house as
they assist their mothers with the house work while boys are more likely to be injured
outside as they tend animals or play.
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The very young child is more prone to falling than the older child. The falls could be
from a bed, a high apartment building or a rough out-doors. Toddlers are more prone to
burns/scalding compared to older children.
Two studies were carried to document the prevalence of accidents in Marigat Division a
rural area in Kenya and in Kibera urban slum of Nairobi. The peak occurrence of
accidents was in the under fives and the prevalence was comparable in boys and girls.
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The following steps should then be taken: -
Blunt trauma, cuts, falls, and puncture wounds are common accidents in children. Cuts
usually results from objects such as knives in the household or farming implements as
children work in the garden. Blunt injuries follow episodes of assault or animal kicks.
Falls are an important form of injury and were found in the studies described above to
be common in the urban environment while puncture wounds were common in rural
areas. Small babies fall from high surfaces where they have been left unattended. In a
few occasions head injuries followed by mental retardation and epilepsy have occurred.
In urban areas toddlers and even school aged children fall down the stairs and from
apartment buildings with inadequate safety measures while school aged children may
fall from trees or from jumping off moving vehicles. Falls from a height put children at
risk of hip injuries.
Thorns pricks are important in rural areas where children walk bare footed. The wound
may become septic and may be a source of tetanus. The principles of management are
as detailed above.
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DROWNING AND NEAR DROWNING MANAGEMENT
Children run the risk of drowning when they play around water without adequate
supervision. High risk groups include toddlers, preschool children and patients with
seizures. A toddler may drown in a bucket or basin filled with water. Older children in
rural areas drown in rivers, pit latrines and excavation sites filled with water.
Management
1. Initiate ventilation -clear the mouth of any debris and hold the child upside down and
pat on the back to facilitate the removal of inhaled water and then do mouth to mouth
resuscitation.
2. Start external cardiac massage if there is no palpable pulse.
3. Give oxygen at the earliest opportunity.
In Hospital
1. All children with near drowning should be admitted for at least twenty four hours
observation, no matter how well they look.
2. Cardiopulmonary resuscitation should be continued until spontaneous breathing is
restored.
3. Children who fail to respond to the above measures should be transferred to an
intensive care unit.
Burns
Burns cause 10% mortality of all hospital admissions. It is estimated that 20 people per
million population die from burns with half of them dying before hospital admission.
Children account for a large proportion of all burns admission in eastern and southern
African countries. Burns are a leading pediatric surgical emergency. They are
responsible for 30% of acute paediatric surgical admissions and, like other accidents
and poisoning, the peak incidence is between one and three years of age.
Scalds are most important burns in childhood usually from hot tea, water and porridge.
The majority of burns occur at home. In the Margate study 82% of the burns were in
children aged less than five years and there were significantly more girls who were
burnt than boys. The possibility of child abuse should always be considered when a
child presents with burns.
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Hospital Management of Burns
There are two methods of treating burns, the open method and the closed method. In
both methods one aims to provide an aseptic environment so that the burn can heal
rapidly. In second and third degree burns topical antibiotics are indicated. The drug of
choice is sulphadiazine although, silver nitrate, povidone-iodine, and gentamicin
ointments have been used.
Open method
In the open method, the burn is left open and a topical agent is applied twice daily. This
method has an advantage in that bacterial growth is not enhanced. However, it has the
disadvantage that the wound is more painful and there is increased fluid loss.
Closed method
Prevention of Burns
1. Make sure hot liquids, fire and match boxes are not accessible to children.
2. Young children should be adequately supervised.
3. The fire places should be out of reach of young children.
POISONING
A poison is any substance that causes harm if it gets into the body. Harm can be mild
(for example, headache or nausea) or severe (for example, fits or very high fever), and
severely poisoned people may die. Almost any chemical can be a poison if there is
enough in the body.
Acute exposure is a single contact that lasts for seconds, minutes or hours, or several
exposures over about a day or less. Chronic exposure is contact that lasts for many
days, months or years.
Routes of Exposure
Through the mouth by swallowing (ingestion)
Most poisoning happens this way. When poisons are swallowed they go to the stomach
from where they are absorbed into the blood. The longer a poison stays in the gut the
more will be absorbed into the blood and the worse the poisoning will be.
Through the lungs by breathing into the mouth or nose (inhalation)
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Poisons in the form of gas, vapour, dust, fumes, and smoke or fine spray droplets may
be breathed into the mouth and nose and go down the air passages into the lungs.
1. Poisoning accidents in the home happen to young children aged between 1 and 4
years with a peak at 2 to 3 years. At this age children want to explore. They can crawl
or walk round the house on their own and by the age of 2 they can probably climb onto
a chair to reach a high shelf. They can open drawers and cupboards, and they may be
able to open screw-top bottles. After the age of five years and particularly in developing
countries poisoning often occurs in groups, usually of friends, for example following food
poisoning, pesticide and carbon monoxide poisoning.
2. Accessibility of the poisoning agent is the single most important environmental risk
factor. Paraffin is the commonest poisoning agent in this region. Children of health
workers who have large amount of drugs in the house or siblings of children on chronic
treatment with drugs such as anticonvulsants, or major tranquillizers are at increased
risk of poisoning
3. Most drug containers in use in the region are easy to open and do not have a child
lock
4. Many pediatric drug preparation are sugar coated or sweetened and may be
mistaken for sweets.
6. Illiteracy contributes to the risk of poisoning in that individuals who are unable to read
will be unable to follow safety precautions written on the labels of various drugs and
chemicals.
7. Inadequate labeling of drugs and chemicals increase the risk of poisoning. It also
leads to lack of recognition of poisoning and late institution of appropriate therapy.
Unfortunately health workers often fail to label the drugs that they dispense.
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8. Administration of the wrong drug or the wrong dose; for example caregivers may
administer different brand names of the same medicine or they may give larger doses
than those prescribed with the hope of speeding up recovery. There are instances
where health workers have administered the wrong medicine or the wrong dose with a
fatal outcome.
Consequences of Poisoning
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Table II: Substances causing poisoning in children
MANAGEMENT
The management of the poisoned child is at two levels; at home where first aid is
administered and in the hospital where specific treatment is given.
First aid treatment should be administered by the person who finds the child after the
poisoning episode. Care should be taken so that the first aid treatment does not cause
severe complications that may be worse than the original poisoning.
The aim of the first aid is to remove the poison before it is absorbed or to delay or stop
the continued absorption of the poison.
1. The mother or the care provider should give a lot of fluids, for example milk or
milk mixed with raw egg to induce vomiting. Administering milk mixed with raw
egg provides proteins that readily bind the poison. Saline solutions should be
avoided because they lead to electrolyte imbalance.
2. Children who are poisoned by paraffin or a corrosive agent should not be made
to vomit.
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3. Containers of medicines or poisons should be brought along to the hospital for
identification.
Treatment in hospital
The clinician should take a brief history, examine the child thoroughly and rapidly and
then do the following:
Small amount of paraffin cause minimal symptoms. A 10 ml dose may be fatal. A dose
of 1 ml/kg causes central nervous system (CNS) depression which manifests as
drowsiness and coma. A history of coughing, choking, wheezing and fast breathing as
well as vomiting is suggestive of aspiration resulting in a hydrocarbon pneumonia that
takes several weeks to resolve completely. Weakness, dizziness, headaches and coma
also occur. An acute hemorrhagic necrotizing disease has been described, evolving
over 24 hours and resolving spontaneously over 3-5 days.
Management of paraffin poisoning
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1. Induction of emesis is contra-indicated because it facilitates the aspiration of
paraffin into the lungs.
2. In severe poisoning a cuffed endo-tracheal tube is used to aspirate the poison
from the stomach.
3. All children presenting with a history of paraffin poisoning should be observed
in hospital for 6 to 24 hours.
4. Supportive care, including oxygen and mechanical ventilation, should be given
as needed. For repeated fits diazepam should be given by intravenous injection.
ORGANOPHOSPHATE POISONING
Mild poisoning presents with anorexia, and tremors of the tongue and eye lids, while the
older child may complain of impaired vision, headache, dizziness, weakness, anxiety,
and substantial discomfort.
Severe poisoning presents with severe diarrhoea, difficulty in breathing, pinpoint and
non reactive pupils, pulmonary oedema, coma, hyperglycemia, and rarely acute
pancreatitis.
Treatment depends on the severity of the poisoning; in a severely poisoned child the
priority should be to establish an airway, administer oxygen, reduce respiratory
secretions through suction, and control convulsions if present.
Specific treatment:
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3. Give activated charcoal to absorb any organophosphate that may be in the
gut.
The patients often present with hyperventilation, sweating, dehydration, and sometimes
diarrhoea and vomiting. In moderate poisoning the respiratory centre is stimulated
resulting in respiratory alkalosis to which the kidney responds by producing alkali and in
the process K+ is depleted and H+ is substituted resulting in acidic urine.
Aspirin poisoning causes metabolic acidosis in the young child that is classified as mild
(blood pH>7.4 and urine pH>6.0), moderate (blood pH<7.4 and urine pH<6.0,) and
severe (blood pH<7.4 and urine pH is <6.0)
In severe cases convulsions and coma occur. Older children may present with vomiting,
hyperpnoea, lethargy, tinnitus, and sudden deafness.
1. Emesis followed by a gastric lavage using a wide bore gastric tube should be
carried out. Salicylates have been recovered in the gut up to 20 hours after
ingestion.
5. Mild aspirin poisoning can be managed successfully with oral fluids. Oral
rehydration solution (ORS) is ideal in that it provides at least 30meq/I of
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Bicarbonate and 20meq/l of K+. Urine pH and that serum salicylate should be
monitored.
8. If the patient is able to take fluids orally ORS, orange juice, bananas and milk
are useful in alkalinizing urine. 1.5g of KCL may be added to 1 liter of ORS to
increase the K+ content to 40 meq/liter.
IRON POISONING
Iron poisoning in children is related to the availability of iron containing tablets in the
house. Severe iron poisoning will depend on the amount of elemental iron that is
absorbed.
Five stages of intoxication occur:
haemorrhagic gastroenteritis 30-60 minutes after ingestion of the iron and maybe
associated with shock, acidosis and coma. This phase lasts 4-6 hours.
Phase of improvement when patient looks better and lasts 2-12 hours.
Phase of delayed shock that occurs 12-48 hours after ingestion and is usually
associated with a serum iron level of>500mg/dl. Metabolic acidosis, leukocytosis and
coma may occur; there may be hyperglycaemia at first and hypoglycaemia later.
Residual pyloric stenosis that usually develops 4 weeks after the initial poisoning. A
plain abdominal x-ray will demonstrate the un-absorbed tables in the stomach.
Diarrhoea, vomiting, leucocytosis (>15, 000µL), hyperglycemia, and a positive
abdominal x-ray have been shown to correlate positively with a serum iron of>300µg/dl.
207
Management of iron poisoning
1. Emesis and gastric lavage using a large bore nasogastric tube should be
carried out.
2. Do not give activated charcoal because it does not bind iron.
3. Desferrioxamine should be given to all patients with signs and symptoms of
severe poisoning such as shock, unconsciousness, convulsions, severe
vomiting or acidosis, or a serum iron concentration greater than 5 mg/l. It can
be given intramuscularly or intravenously.
PREVENTION OF POISONING
1. Safe storage of drugs and household agents, out of reach of children and
preferably under lock and key.
4. Health workers should give health education on safe use of drugs dispensed
to patients.
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SNAKE BITES
Snake bites are common in rural, peri-urban and hilly areas. Children and adolescents
engaged in outdoor play are the most vulnerable group. Most snakes are non-
poisonous. However the mambas, viperidae (true vipers) and afro-asian cobras are
some of the deadliest snakes. It is important that the health workers be familiar with the
common snakes in the area and their physical appearance in order to determine
whether the attacking snake is poisonous or not.
All snake bites should be considered potentially dangerous and urgent treatment should
be instituted.
Snake bites are more serious in the children because of the relatively large volume of
venom injected into the small volume of a child.
The snake bite victim is usually frightened and unable to give history. Examination of
the wound is useful since bites by non poisonous snakes lack distinct fang marks and
there is no swelling or pain.
- Bite site: pain, swelling, tissue discoloration and regional lymph node swelling.
- Hemorrhagic symptoms: bleeding at the wound site, venipuncture sites,
epistaxis
and bleeding in other body parts is pathognomonic of a snake bite.
- Danger signs: drowsiness, slurred speech, excessive oral secretions, difficulty
in breathing and coma.
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REFERENCES
1. World report on road traffic injury prevention. World Health Organization. 2004
3. Reece R.M. and Godin M.A. Injury and injury prevention. Pediatric Clinics of North
America, 1985, 42-60
5. Baures P. The management of the road traffic victim. Post graduate doctor. June
1984. vol. 6 page 174.
9. Watt CH. Poisonous snake bites treatment in the United States. JAMA 1978;140
(7):654-6
10. Oloo MA. Prevalence study on accidents in persons under twenty years of age in
Marigat Division, Baringo. MMed (Paed) Dissertation, University of Nairobi.
11. Yuko AC and Kitili PN. A prevalence study of accidents and poisoning in persons
under 20 years of age in a Nairobi slum, Kibera, Laini Saba. Unpublished manuscript,
Department of Paediatrics, University of Nairobi.
12. Rumack BH. Poisoning in Current Paediatric diagnosis and treatment.8th edition.Ed.
Kempe CH, Silver HK, O’Brien D. Lange Medical Publications, Los Altos, California.
210
CHAPTER 17
CARDIOVASCULAR DISEASES IN CHILDHOOD
Christine Yuko-Jowi, Gabriel Anabwani
The commonest childhood cardiovascular problems are congenital and rheumatic heart
diseases. These two causes account for the majority of patients being seen with heart
disease in most east and southern African countries. Congenital heart diseases are
malformations of the heart and blood vessels which are present from birth. Rheumatic
heart disease results from an inflammatory process of the heart following upper
respiratory infection by beta haemolytic streptococcus. Less common causes of heart
disease in children include viral myocarditis and pericarditis, connective tissue diseases,
Kawasaki’s disease, tuberculous pericarditis and heart disease due to nutritional
deficiencies.
How Can One Identify Functionally Important Heart Diseases In Infants And Children?
Suspect congenital heart disease in any newborn, infant or child who presents with any
of the following symptoms:
Older children may complain of shortness of breath with exercise, fatigue, dizziness or
palpitations. Chest pain and syncope may be associated with lesions that obstruct the
flow of blood. History may reveal evidence of poor maternal health such as diabetes or
chronic alcohol or drug use.
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How does one examine a child with a suspected heart problem?
Step 1: Assess whether the infant or child is acutely ill or potentially stressed and
therefore in urgent need for referral for further investigation and management
Step 2: Check if the infant cyanotic or Acyanotic.
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PERCUSSION: Percussion of the chest is an important part of a respiratory
examination but is of limited value in a cardiac examination.
Heart sounds: A loud first heart sound is associated with mitral stenosis. A fixed split
second heart sound is associated with atrial septal defects. The second heart sound
may be loud in severe pulmonary hypertension whereas it may be soft or inaudible in
pulmonary valve stenosis.
Murmurs: Are usually the main reason why paediatric patients are referred to hospital
for cardiovascular assessment. Murmurs may be systolic, diastolic or continuous.
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lesions present with frequent chest infections, failure to grow and tachycardia. In the
absence of pulmonary hypertension the second heart sound is normal on auscultation.
A long or pansystollic murmur is heard best along the lower left sternal border. A chest
radiograph shows cardiomegaly with increased pulmonary vascular markings. An
electrocardiogram shows left ventricular hypertrophy when the VSD is large. Two
dimensional Echocardiogram is the best tool used to diagnose the type and size of
VSD, and any associated complications. Cardiac catheterization may be useful in
assessment of pulmonary pressures in selected patients. Small or moderate VSDs may
close spontaneously. However, large VSDs can cause irreversible complications or
heart failure and are treated by surgical closure. Figure 1 is a two dimensional picture of
a VSD.
VSD
RV
AV
LV
LA
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Figure 4- cardiac catheterization picture showing balloon dilatation of the pulmonary
valve.
215
pulses and continuous murmurs along the left upper sternal border. A chest radiograph
may show cardiomegaly with increased pulmonary vascular markings. An
electrocardiogram shows left ventricular hypertrophy when the PDA is large. Two
dimensional echocardiogram with colour flow Doppler is the best tool used to confirm
the diagnosis of PDA and any associated complications. Cardiac catheterization may be
useful in assessment of pulmonary pressures in selected patients. Treatment is by
surgical ligation or occlusion using special devices as soon as the diagnosis is made.
Untreated PDA can lead to congestive cardiac failure, pulmonary hypertension and is
prone to infective endocarditis.
PDA
AO
MPA
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be dilated using balloons and stents during cardiac catheterization.
Aortogram showing
coactation of the aorta
These congenital malformations are complex and associated with morbidity and
mortality during the neonatal period. They present with central and peripheral cyanosis.
Tetralogy of Fallot
This is the commonest type of cyanotic congenital heart disease, presenting with
cyanosis and a systolic murmur within the first month of life. This abnormality has four
basic components: a large ventricular septal defect, pulmonary subvalvar and valve
stenosis, overriding aorta and right ventricular hypertrophy. The patients can sometimes
present with extreme cyanosis and hyper cyanotic or “tet” spells. Hyper cyanotic spells
can be life threatening and often need urgent recognition and management.
Management of the spell includes putting the child in knee chest position, giving
intravenous fluids to improve on the hyper viscosity, propranolol to improve the
infundibular spasms and peripheral resistance. Morphine and sodium bicarbonate may
be indicated in severe states. Treatment of tetralogy of Fallot is surgical , either
palliative by putting a Blalock-Tausig (BT) shunt, or total correction through open heart
surgery to resect the pulmonary infundibular and close the VSD using a patch.
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pharyngitis virtually eliminates the risk of acute rheumatic fever; lack of access to good
medical care remains a risk factor to developing ARF. Although the prevalence of acute
rheumatic fever appears to be declining even in developing countries, the profile of the
disease appears to be changing, now running a sub acute course and the severity of
the cardiac process has not ameliorated.
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Differential diagnosis
Fever and arthritis must be differentiated from other conditions causing polyarthritis in
children like juvenile rheumatoid arthritis, infective endocarditis, sickle cell anaemia, and
immune complex disease. Carditis and heart murmurs must be excluded from functional
murmurs, mitral valve prolapse, viral myocarditis and congenital heart disease.
Arthritis
Arthritis is the earliest and most common clinical feature which is present in
approximately 80% of patients. It presents as a painful migratory arthritis involving large
joints such as knees, ankles, elbows, or shoulders. The migratory polyarthritis is usually
associated with fever. The arthritis of RF rarely affects the small joints of the fingers,
toes, or spine; and the arthritis rarely causes permanent joint damage.
Carditis
Signs of carditis may include persistent tachycardia, a heart murmur which was not
present previously due to valvulitis; a pericardial friction rub (due to pericarditis) and
cardiac enlargement (due to myocarditis) Progressive congestive heart failure, a new is
the most lethal manifestation. Mitral and aortic regurgitation are the common valvular
damage during the acute process.
Sydenham chorea
Presents as involuntary, uncoordinated purposeless movements that occur one to six
months after the initial streptococcal pharyngitis. Sydenham’s chorea is self limiting and
recovers without neurological sequelae. This type of chorea is now rare seen.
Erythema marginatum
This presents as none-itchy patches of pink rashes with sharp border, which may
eventually spread into each other that are often seen on the inner thighs. Erythema
marginatum is strongly associated with the development of heart complications.
Subcutaneous nodules
Subcutaneous nodules present as bumps the size of peas under the skin. These
nodules most commonly occur over the knees and elbows and over the spine. These
nodules are non-tender and feel hard to the touch. Subcutaneous nodules are strongly
associated with the development of cardiac complications.
Unusual presentations, such as indolent carditis and isolated chorea, may also occur.
Even rarer manifestations include epistaxis and abdominal pain due to serositis.
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Figure 1-Two dimensional echocardiogram Parasternal long axis showing
thickened and clubbed mitral valve leaflets and dilated left ventricle.
An important consideration is how long one should give secondary prevention for
RF/RHD. The WHO recommendation is shown in the table below:
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Other therapeutic measures
Rest: Patients with carditis should have bed rest until the signs of cardiac inflammation
have subsided.
Antinflamatory agents: Acetyl salicylic acid (Asprin) has dramatic effect on arthritis but
has no effect on carditis. High doses are used (70-100 mg/kg). Corticosteroids are used
in patients with carditis. Prednisone 1-2mg kg/day divided in one or two doses for two
weeks and tapered over a week.
For Sydenham’s chorea Haloperidol 0.5- 1mg /kg (maximum dose 5mg) until symptoms
are controlled. Prolonged treatment may be required in some patients especially those
with recurrent symptoms.
Heart failure may occur in severe carditis or rheumatic valvular disease. Patients with
heart failure should managed with oxygen, rest, fluid restriction, furosemide (1-2 mg/kg
per day) and digoxin 0.125 mg od. Patients with heart failure as well as those with
carditis or cardiac complications should be referred for specialist care.
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CHAPTER 18
INTRODUCTION
The skin is the largest organ in the body. It protects us from the environmental hazards
such as ultraviolet light and infections among other functions. Skin problems are
common. Many of these problems never present at health care facilities as the parents
may think they are minor and indeed some of the heal without treatment. Usually by the
time a child is brought to a health facility there are either multiple lesions or have the
lesions have not responded to home care remedies. Skin lesions may be part of a
systemic disease or an allergic reaction. HIV/AIDS which presents with skin diseases in
over 90% of the cases has increased the prevalence of skin conditions.
The purpose of this chapter, therefore, is to enable the student understand basic
dermatological terminology, recognize common skin diseases in children and
adolescents and treat them.
Objectives:
At the end of this chapter, the student should be able to:
Define and identify primary and secondary skin lesions.
List the common skin diseases seen in children.
Recognise common skin diseases.
Understand common dermatological investigations.
Treat the common skin diseases.
Use topical steroids rationally.
Learning Experiences:
To identify a skin lesion one has to consider the following about the lesion:
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Contains fluid or not.
Type of fluid is in the lesion.
Widest diameter of the lesion ( < 1cm ).
These are the lesions that occur when the skin disease starts, without interference by a
physical activity. They include:
Papule - Elevated lesion that is 1cm or less in diameter and does not
contain fluid.
Cyst - Nodule that is filled with expressible material that is either liquid
or semi-solid.
These lesions result from external interference on the primary lesions such as
scratching, drying, etc. They include:
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Fissure - Thin linear tear in the epidermis that usually indicates dry
skin.
7. Atrophy - Loss of skin tissue. May involve the epidermis making the
skin to appear thin and wrinkled. When the dermis is
involved there is a detectable depression.
N.B: Photographs of these lesions are beyond the scope of this manual but can be
found in atlases on skin conditions
Definition:
Dermatophytes are filamentous fungi that possess enzymes to digest Keratin. They
infect the stratum corneum, hair and nails.
Nomenclature:
The nomenclature used in diagnosing dermatophyte skin infections is based on the part
of the body involved and the fact that the cause was earlier thought to be worms.
Hence the prefix, Tinea refers to worm (Latin) and the suffix denotes the part of the
body infected.
Tinea capitis - Dematophyte infection of the scalp and the hair of the scalp.
scalp.
Tinea corporis - Infection of the body.
Tinea cruris - Infection of the legs and thighs.
Tinea pedis - Infection of the feet.
Tinea manuum - Infection of the hands.
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Aetiology:
The fungi that cause dermatophyte infections are grouped in 3 genera namely
Trichophyton, Epidermophyton and Microspora.
Examples:
Trichophyton tonsurans, M. ondini, M. Canis. T. Verucosum and E. Flocosum.
Most common cause of T. Capitis is T. Tonsurans.
Transmission:
Clinical Presentation:
These infections present in various ways depending on the type of infection. On the
scalp there may be papules, patches of hair loss, scales, and occipital
lymphadenopathy. On the body there will be patches with clear centre and active
advancing borders with scales. On the hands and feet there are scales, and interdigital
debris. All these may be accompanied with some itch.
Investigations:
Potassium Hydroxide (KOH) Test is used to diagnose these fungal infections. The
lesion is scrapped on the margins if it is on the scalp or the body and the test is done.
One sees hyphae.
2. Cultures: Fungal cultures are rarely required. The fungi are cultured on
Sabaraund Dextrose agar.
Treatment:
Generally, T. capitis and T. pedis are treated using oral antifungal drugs. Topical
agents are less effective. The other dermatophyte infections can be treated by either
oral or topical antifungal agents.
Griseofulvin tablets : 15 – 25mg/kg/day for 6-8 weeks. It is given once daily. This is the
standard drug for treatment of T. capitis.
Terbinafine – 250 mg OD for children over 40 kg, 125mg OD for children 20-40 mg and
62.5mg for children < 20 kg for 2-4 weeks. Used in the treatment of T. Capitis, T.
manuum and T. pedis.
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Itraconazole – 3-5mg/kg/day for 4-6 weeks used in T. capitis.
Topical antifungal drugs are useful in T. corporis, T. cruris, T. manuum. They include
Whitfield’s, imidazoles, and tolfenate among many.
There are several skin diseases that are caused by bacterial and present with pustules
and blisters
A) Impetigo:
Definition: Superficial skin infection caused by gram positive bacterial usually S. aureus
This is very common in children.
Clinical features:
Starts as a single superficial lesion which is usually ignored by the parent until multiple
lesions occur. Other family members may be affected. The child may have atopic
eczema as well.
Most common lesion is a honey coloured crust (honeycomb appearance) without
ulcerations or erythema. Removal of the crust leaves an erosion
Lesions are mostly distributed on the face
Diagnosis is usually is usually clinical
Treatment
1. Topical antibiotics e.g. bacitracin (neosporins) and bactroban (mupirocin) are used for
small lesion. Systemic antibiotics are preferred where the lesions are large. Use a
penicillinase resistance antibiotics e.g. Dicloxacillin or oral erythromycin
Older children give 250mg qid for 7-10 days, younger child and infants give
30mg/kg/day in for divided doses for 7-10 days
Complications
Acute glomerulonephritis may follow streptococcal but not staphylococcal infection.
Treatment
As in impetigo but soak the lesions with either soap and water or an antiseptic before
applying the topical antibiotic. Systemic antibiotics are recommended because of the
renal complication
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3. VIRAL INFECTIONS
With the advent of HIV/AIDS, there has been an increase in viral infections. Viral
infections present with vesicles, blisters and growths. They have no cure.
Aetiology
There are 3 DNA viral families that commonly cause skin diseases.
These are:
a) Herpes: Herpes simplex virus (HSV), Herpes zoster (shingles), and
Varicella zoster (chicken pox)
b) Parpovirus : Human papilloma virus
c) Pox: molluscum contagiosum
Pathogenesis
These viruses are transmitted through direct inoculation into the skin except for
varicella/zoster which is spread initially through respiratory system by inhalation. They
penetrate the epidermal cells where they replicate. Their location in the skin determines
the lesions produced
Warts and Molluscum contagiosum replicate in the keratinised cells (upper epidermis)
leading to hyperplasia and appear as growths
HSV replicates in hours, devastates the cells leading to lysis and death of the host cells
with formation of vesicle.
Herpes simplex
There are two types: HSV-1 which causes oral infection or perioral infection and HSV-2
causes genital infection. 90% of oral infections occur in children while most of the
genital infections are in post pubertal individuals after sexual exposure. Finding of
genital HSV in a young child suggests sexual abuse.
Clinical features
There is usually a prodromal itching and pain at the site of the lesion. This is followed by
appearance of vesicles that are grouped. The vesicles are mostly found in the perioral
region in children. Vesicles rupture, weep and crust. Healing occurs within one week.
Diagnosis is usually clinical.
Treatment
Acyclovir is the drug of choice. It is available as a topical and oral preparation.
1. Topical – 5% acyclovir ointment is used in the treatment of initial genital herpes and
localized peri-oral infection
2. Oral acyclovir is used in treating primary and recurrent infections
3. Intravenous Acyclovir is used in severe infections in immunocompromised patients
227
Clinical features
There is a prodromal period when the child will have pain and itching before eruption.
Vesicles appear along a dermatome and have an erythematous base. They are usually
these are unilateral but may be bilateral in HIV infected patients
Diagnosis is usually clinical
Treatment
1. Analgesics: the choice of analgesic has to be commensurate with the degree of pain
2. Acyclovir: dosage of 10mg/kg every 8 hours intravenously for 7-10 days.
3. Acyclovir 800mg 5 times a day for 7-10 days in adults.
Varicella zoster
Definition: acute highly contagious intra-epidermal vesicular eruption caused by
varicellar zoster virus.
Incidence: 90% of cases occur before 10 years of age.
Clinical features
The incubation period of 2-3 weeks is followed by a prodromal stage which lasts 2-3
days. Presents with: chills, fever, malaise, headache, sore throat, anorexia, and cough
but these are often minimal. An intensely itchy rash appears. All types of lesions are
seen at the same time. They include: macules, vesicles, papules, pustules and crusts
Diagnosis: usually clinical.
Treatment
A) Supportive.
1)) antihistamines
2) calamine lotion
3) paracetamol( do not use aspirin due to possibility of Rye’s syndrome)
B) Specific treatment
Note: In difficult to diagnose varicellar/zoster cases a Tzanck test can be done. Tzanck
test reveals multinucleated giant cells.
Molluscum Contagiosum
Definition – Viral infection of epidermal cell caused by a pox virus
Common in childhood
Presents with papules 2-5mm wide dome shaped umbilicated single or grouped on the
trunk, face and extremities. May be generalized in immunosuppressed children
Diagnosis is usually clinical.
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Warts
Definition. These are benign growth caused by infection the epidermal cells with
papilloma viruses
Predisposing factors include:
HIV infection
Renal transplant
Use of steroid
And use of cytotoxic drug
Ano-genital occurrence in children suggests sexual abuse
Clinically appear as:
1. Verruca vulgaris (common wart) which may be a papule or nodule with corrugated
surface that is flesh coloured and firm with a black dot. Distributed on fingers and hands
3. Plantar Wart single and painful found of the plantar surface of the foot
Common Warts –
a) 17% Salicylic acid ointment
b) 17% Salicylic acid in polyacrylic vehicle
c) Cantheridine
d) cryotherapy
Flat warts
a) Retin A
b) 5% salicylic acid ointment
Plantar warts
10% formaldehyde
Salicylic acid plaster
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Condylomata acuminata
25% podophyllotoxin
Cryotherapy (preferable)
4. SCABIES
Definition: Infestation of the epidermis by the sarcoptes scabiei.
Epidemiology:
Scabies is a common disease worldwide but is more common in the developing
countries. The incidence fluctuates over the years with peaks following 30 year cycles.
Commonly occurs among school children and institutionalized patients. Predisposing
factors include poor socio-economic status, poor hygiene and low immunity especially
HIV/AIDS.
Clinical features
Pruritic papules (predominant lesion), vesicles and pustules are found most commonly
in the finger webs, wrists, elbows, maxillae, girdle area and feet but may be generalized.
The face is usually spared except in babies.
May occur in other family members and the baby sitters May be contracted from pets
Secondary bacterial infection can occur especially in the immune compromised.
Diagnosis is often clinical but by finding a burrow usually in the finger webs.
Investigations:
Scalpel (No.15) is used to scrap the lesion. The highest yield is usually from the
burrow. The specimen is put on a drop of oil on a microscope slide and examined. One
may see the adult mite, eggs or faeces.
Treatment:
Mainstay of treatment is topical.
Benzyl Benzoate: this is applied on the whole body from the neck down. Should not be
applied on the head. Applied at night for 3 days. Patient should not bath once this
applications start until they are finished then he/she may bathe on 4th day.
Definition:
Eczema: Greek word that means “to boil over”.
Atopic (Eczema) dermatitis is a chronic, pruritic condition of the skin that is associated
with personal or family history of atopic diseases such as bronchial asthma and /or
allergic rhinitis.
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Clinical features
Age of onset commonly starts after 2 months. Pruritis – most prominent symptom. In
neonates it appears as cradle cap; papulo-vesicles on face and extensor surfaces in
infancy; and in older children flexural lichenification is found.
Thirty percent of children have associated allergic rhinitis which is also found in2/3 of
their family members. Food allergy – occurs in 10% of the patients. Contact allergy –
occurs in 10% of the patients.
Mode of presentation:
Acute - presents with papules and vesicles.
Chronic - lichenification
Diagnosis is usually made on clinical grounds
Therapy:
Management is usually difficult because of the chronic nature of the disease
Aim of treatment is to reduce inflammation and itching. The mainstay of treatment is
topical steroids and systemic antihistamines. Initiate treatment with a potent steroid and
taper down to a less potent one.
Use ointments for dry lesions, creams for wet lesions, and lotions where there is hair.
Topical Steroid Therapy:
Topical steroids are classified from the most potent to the least potent (Class I to class
VII) respectively. Example class I is betamethasone and Class VII is hydrocortisone.
Class I should be used for a maximum of 14 days (where applicable) and changed to a
less potent one.
Avoid class I steroids in:
Children aged less than 5 years.
Face
Groin of all age groups
Axillae
Antihistamine Therapy:
There are sedating and non-sedating antihistamines.
Sedating antihistamines are more effective in controlling the itch than non-sedating.
Example of sedating antihistamine is chlorpheniramine.
Example of non-sedating is loratadine.
Antibiotic Therapy:
Antibiotics are used in cases where the lesions are weeping. If the lesions are localized
then topical antibiotics such as mupirocin are used. If it is generalized then oral
antibiotic effective against S. aureus such as cloxacillin is used.
Atopic Advice:
Children with this disease should be advised to:
Bath in warm water using medicated soap.
Avoid woolen fabrics instead use cotton clothes and beddings.
Moisturize the skin at least twice a day. Vaseline pure petroleum jelly is commonly
recommended.
231
RECOMMENDED READING AND REFERENCES:
S.O. Ayaya, K.K. Kamar, R. Kakai. Aetiology of Tinea Capitis in School Children, EAMJ
(78) Oct 2001, pp 531 – 535.
Okafur J.I. and Agbubaerulehe A.K. Dematophytoses among school children in Aba,
Abia State, Nigeria and some physiological studies on isolated aetiological agents. J.
Common Dis 1998 30; 44 – 9.
Figureson J.I., Hawravek T, Abraham A, and Hay R.J.,Tinea capitis in south Western
Ethiopia: A study of risk factors for infection and carriage . Int. J. Dematol. 1997 361 :
661 – 6.
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CHAPTER 19
INTRODUCTION
No discussion of health services is possible without consideration of budgeting. Where
funds are limited, as is the case in most economically less developed countries,
priorities must be set so that essential drugs are always available for those needing
them. Thus provision of essential drugs is a fundamental element of any comprehensive
primary health care programme. Getting essential drugs to people under a well
organized supply system, proper prescription by the health personnel and appropriate
drug use by the consumer are all essential ingredients of the Essential Drug
Programme. It is therefore important for the student of medicine to understand what
essential drugs are, their pharmacology, dosage and indications.
Essential drugs may be defined as cost-effective drugs with proven efficacy for which
adequate standards of quality have been established and which meet the health needs
of the majority of the population. These are discussed in Section A of this chapter.
Section B deals with rational use of antibiotics.
OBJECTIVES
At the end of this chapter, the student should be able to:
Explain the concept of essential drugs;
Outline criteria for choosing essential drugs;
List essential drugs for a defined community;
Discuss guidelines for rational prescribing of antibiotics.
LEARNING ACTIVITIES
To aid the student in learning about the operative essential drugs in a particular health
locality visits to at least two health centers (He) considered representative of the area
are recommended. At each of these health facilities the student should engage in the
activities listed below:
Correlate the essential drugs available in the HC to the pattern of disease in the area;
Follow the steps of drugs procurement, storage, distribution and their use in that
He.
Use these findings to assess the performance of the essential drugs programme
for the area.
Provide immediate feedback on your findings to the HC staff.
Prepare a written report summarizing your findings and conclusions.
SECTION A: THE CONCEPT OF ESSENTIAL DRUGS
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Within developing countries, most drugs are consumed in urban centers while
the rural areas contain the majority of the population. Inequity in the distribution
of health resources including drugs supply is crucial because when drugs are
frequently unavailable patients tend to shun such health facilities. The Essential
Drug concept was adopted by the WorId Health Assembly in 1975 in order to
overcome the problems of cost, production, distribution and availability.
Any selection of essential drugs must therefore depend on the following key
criteria, namely:
The pattern of disease prevalence in the community;
The available treatment facilities.
The training and experience of the available personnel.
The financial resources available.
The prevailing demographic and environmental factors.
Typically a very short list is compiled for community health workers while the
most comprehensive lists are reserved for large urban and regional hospitals.
Village health posts and dispensaries should receive only commonly used drugs. A
health centre should first be given emergency drugs. For children, oral treatment using
syrups and tablets is highly recommended. Trained community health workers can be
given six basic drugs to treat common conditions prevalent in their areas. Such drugs
include: paracetamol tablets; chlorhexidine solution; acetylsalicylic acid tables; oral
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rehydration salt sachets; and tetracycline eye ointment or drops.
Text box:
Effecting the concept of essential drugs can have certain advantages, including
economic saving. In addition ;
Before establishing essential drug programmes, there is need for selecting essential
drugs using WHO criteria as a guide. The steps involved in establishing essential drug
programme can be summarized as follows:
At country level there are good reasons for establishing an essential drugs programme
as this can avoid:
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Organization of an Essential Drug Programme
National Level
At the national level there is an essential drugs unit or department in the
Ministry of Health. While functions at this level vary from country to country,
they include planning, acquisition of funds, regulatory control, drug procurement
and distribution, training and liaison between ministries.
Health centres and dispensaries are the key primary care stations implementing the
programme. Therefore, managing drugs in these health .units is one of the most
important functions of a primary health care worker. Management at these stations
involves ordering, receiving, storing and distribution of the drugs. Health workers at this
level should participate in educating the community in rational and proper drug usage.
Community Level
Community participation in the storage, distribution and use of their own drugs is an
essential component of the programme. Community members have to understand,
cooperate and work with health providers to achieve success.
Drug Procurement is the most important activity in implementing the essential drug
programme. It involves estimation of drug quantities. There are three different ways to
estimate drug needs:
Population-based estimation calculates the theoretical needs of a given
population based on the burden and pattern of disease in the community.
Although this is probably the ideal method, it is not attainable in the short time
especially where the health service do not cover the entire population or
community;
Service based estimation depends on health service statistics only and considers
patients who come for care. It enables us establish objectives so as to avoid
stock outs. This implies that health services have been in existence for some
time and past records of diseases treated and drugs prescribed are available
and reliable.
Consumption-based estimation is the most commonly used method. It requires a
system that provides satisfactory information on monthly drug consumption and
stock level in health-care units throughout the year. However, this method can
under-estimates true demands because of lack of information on diseases
treated.
236
Once the drugs are procured, they are packaged in kits and distributed regularly to
various health units according to their requirements. Regardless of the type of
distribution preferred accurate record keeping is essential.
When essential drugs are received at the health unit it is important to ensure that (a) the
drug kits are sealed; b) the kits are not damaged; c) each kit is opened carefully and the
contents checked for signs of damage (leakage, broken glass, open tins, broken
packets etc); (d) the contents of each kit are checked against the packaging slip; e) for
each drug package, the expiration date, the manufacturer's batch number and
identification of the manufacturer are noted and recorded; f) any damages or shortage
are reported to the person in charge with explanations; and g) the drugs are then
recorded into the stock recorded book and stored.
Monitoring the whole programme ensures proper implementation of the drug 'policy. It is
based on stock record cards. At the end of each month, stock inventory should be
done. The results of the inventory are used to facilitate timely ordering of drugs and
rescheduling of the drugs kits.
All such, problems bust be anticipated and vigorously dealt with, if the noble aims of
this programme are to be achieved.
We are entering a new era where much more attention will be paid to children’s
entitlement to well validated, safe and effective drug therapy. This important process
began with WHA resolution 60.20 “Better Medicines for Children” passed by the World
Health Assembly in May 2007.(1) Subsequently, on December 6, 2007, the WHO
formally began implementation of a related action plan that had been recommended
through the EML process.
The world’s children have waited too long for improved access to well validated
therapies for prevention and treatment of acute and chronic disorders. The unmitigated
burden of illness related to suboptimal treatment has fallen across the entire age
spectrum from infancy to adolescence and the consequences have been especially
grave in African countries where so much of the overall burden of childhood illness
resides. Physicians, pharmacists, and child advocates have been aware of the
consequences of inaction but somehow public action has languished for almost half a
237
century after general awareness of the challenge in optimal pediatric pharmacotherapy
was awakened by the chloramphenicol misadventures of the 1950s.
We have now reached a point at which there are an estimated 5 million deaths annually
among children 5 years or younger that could be prevented by effective, affordable,
accessible drug therapy.
The approval and promulgation of a WHO list of essential drugs for children (EMLc) is a
step forward(2); a necessary but not sufficient condition for the improvement of therapy-
related outcomes in children. Now that this critical first step has been taken it is
important to focus attention on the need for international regulatory harmonization and
for the urgent need to develop and test appropriate new pediatric formulations. More
attention must be paid to region-specific needs identified through formal needs
assessments.
Key actions:(3)
1. closing the know-do gap: This can be achieved in the context of many common
childhood diseases through the development and dissemination of best practice
guidelines.
3. promoting safe medications practice in hospital and community child health care
settings
As it is not possible to know everything necessary about all the drugs available,
experienced child health clinicians tend to use a few important or representative
preparations. Nevertheless, whenever a drug is to be prescribed for a patient, the doctor
should always consider the following key points:
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2. Is the cost of treatment acceptable?
The cost of some very similar drugs can vary by a factor of up to 200. Since someone
must pay, consideration of cost is only rational. Thus the cheapest effective agent
should be chosen over more expensive medications. This will leave money available for
other needs such as some expensive but essential drugs.
239
the formula (BSA/1.8) x adult dose, where 1.8 is the BSA of the standard 70kg human.
A simple formula for calculating the BSA is height (cm) x weight (kg) 3600
Thus, a child weighing 10kg and 72cm long has a BSA of 10 x 72 = 0.45m2 3600
N.B. Both formulae require square root sign. Formula is taken from the WHO pocket
book of Hospital care for Children, page 325.
Section B3. Rational antibiotic use: common infectious conditions
Below is a series a tables (adapted from Guidelines to. Drug Usage) of common
infectious diseases and conditions outlining their specific antimicrobial therapies,
dosage and same useful notes.
Tetanus Benzylpenicillin
50,000U /kg/dose
daily in divided
doses;
If serum is given, start with
plus tetanus test dose and ensure
antitoxin 10,000U epinephrine I: 1000 is
1M once drawn up and ready.
240
Older children > 13
years ciprofloxacin
Opthalmia
neonatorum
Plus
erythromycin
50mg/kg daily in 3
divided doses.
241
cotrimoxazole 24 -30 If there is chronic discharge
mg/ kg/ dose every 12 (>2 weeks) antibiotics are
hours, all for 5-10 days. usually not effective and
should not be used: ear
wash outs and keeping the
ear dry by wicking yield the
best results.
Or
cotrimoxazole 24-30
mg/kg every 12 hours
Duration: 7 to 10 days
Severe Pneumonia
benzyl penicillin 50 000 For immunocompromised
units/kg every 6 hours children including HIV and
severe malnutrition add plus
gentamicin (7.5 mg/kg once
daily)
If evidence of If empyema is
staphylococcus including confirmed under
pustules : water seal drainage
cloxacillin 50-100
mg/kg/day iv or im AND
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gentamicin 7.5 mg/kg iv
once daily
Atypical Erythromycin 15
pneumonia mg/kg/dose 3 times a day
for 7 days
Once daily
Continuation phase:4
months
Isoniazid 5 mg/kg /day
and Rifampicin 10 mg/kg
/day
Table 3.
Gastrointestinal
disease
243
shedding of vibrio cholerae
Or
Sulfamethoxazole 20
mg/kg and trimethoprim 4
mg/kg daily in 2 divided
doses
Table 4.
Genitourinary
disease
244
Recurrent UTI Suppressive therapy in Investigate urinary tract to
children with trimethoprim rule out anatomic
2 mg/kg daily and abnormality
sulphamethoxazole 10
mg/kg daily in 2 divided
doses
Or
Nitrofurantoin 2
mg/kg/dose 3 times a day
Table 5.
Musculoskeletal
Pyomyositis Surgical drainage.
cloxacillin 25 mg//kg/dose
4 times a day for 7 days
Chloramphenicol 25
mg/kg/dose 4 times a day
for 7 days
Table 6. Neurologic
conditions
245
doses
Benzylpenicillin
75,000/kg/dose 4 times a
day for 10 days
AND
Prophylaxis to contacts:
ciprofloxacin or
cotrimoxazole
246
Duration: minimum 14
days up to 21 days
Followed by:
Then
Maintain fluconazole
3mg/kg/day
Brain abscess Metronidazole 7.5 mg/kg Surgical aspiration or
/dose 3 times a day excision may be indicated
PLUS
Cloxacillin 25mg/kg/dose
4 times a day
PLUS
Gentamicin 7.5mg/kg
once daily
Duration: 6 -8 weeks
Pathogens that are resistant to all normally appropriate essential drugs are increasingly
emerging in various countries or regions. In such instances a reserve antimicrobial is
needed. A reserve antimicrobial is an antimicrobial that is useful for a wide range of
infections but, because of the need to reduce the risk of development of resistance and
because of its relatively high cost, it is not recommended for unrestricted (widespread)
use.
Examples:
247
appropriate essential drugs are high or for specific indications, as listed below. a. beta-
lactimase inhibitor amoxicillin + clavulanic acid is active against many of the enzymes
produced by enterobacteria . A specific indication for its use is in polymicrobial
infections related to surgical conditions of the intestinal tract and female genital tract.
Amoxicillin remains active against many common bacteria such as -haemolytic
streptococci and a high proportion of Haemophilus influenzae strains in many countries.
The levels of penicillin resistance in Streptococcus pneumoniae do not at this time
justify replacement of the use of penicillins in the treatment of respiratory tract
infections.
For typhoid fever and other systemic salmonella infections where there are strains of
Salmonella resistant to chloramphenicol, amoxicillin and trimethoprim +
sulfamethoxazole.
For severe shigellosis where Shigella spp. strains exist that are resistant to ampicillin,
chloramphenicol, trimethoprim + sulfamethoxazole, tetracyclines and nalidixic acid.
248
Methicillin-resistant Staphylococcus aureus strains are usually resistant to all -lactam
antimicrobials and also to unrelated drugs such as erythromycin, clindamycin,
chloramphenicol, the tetracyclines and the aminoglycosides. The only effective reserve
drug for infections due to these multiresistant organisms is vancomycin, which is
expensive and must be administered intravenously.
249
REFERENCES
1. WHO expert panel on Essential drugs list: The use of essential drugs. Eighth report
of the WHO Expert Committee (including the revised Model List of Essential Drugs).
World Health Organ Tech Rep Ser. 1998; 882:1-77
2. File T, Haley, Rational use of antibiotics to respiratory tract infections. Am J Manag
Care 2002; 713-727.
3. Arroll B, antibiotics for upper respiratory tract infections: an overview of Cochrane
reviews. Respiratory Medicine, 99: 255-261
4. World Health Organization. Essential medicines for children. Making medicines child
size. http://www.who.int/childmedicines/en/index.html
5. WHO model list of essential medicines for children.
http://www.who.int/childmedicines/publications/EMLc%20(2).pdf (accessed 29 October
2008).
6. MacLeod, Stuart; Peterson, Robert; Wang, Yi; Li, Zhiping; Gui, Yonghao; Schaller,
Jane. Challenges in International Pediatric Pharmacology: A Milestone Meeting in
Shanghai. Pediatric Drugs 2007;9:215-8.
7. Handbook on Paediatric AIDS in Africa by the Network for the Care of Children
Affected by AIDS 2006.
250
CHAPTER 20
INTRODUCTION
The children in especially difficult circumstances – (CEDC) – are children whose basic
needs such as shelter, food, education, health care and security are not met due to
prevailing adverse conditions in a community. Group or individual acts may cause harm
to children and/or prevent them from realizing normal growth and development causing
them to be in difficult circumstances.
High rate of population growth and in some African countries and increasing
urbanization in a time of economic stress is breaking down families as well as
community support systems for disadvantaged children. Consequently, large and
growing numbers of children end up in especially difficult circumstances.
OBJECTIVES
At the end of this chapter the learner shall be able to:
Define children in difficult circumstances
Discuss the underlying causes
List the categories of CEDC
Discuss psychosocial problems among CEDC
Describe the main features of the various categories
Describe health management of children in emergency situations
Provide guidelines for prevention of the problem
LEARNING ACTIVITIES
Visit streets of big towns and find out if there are street children (families)
Obtain and read a copy of the convention of rights of the child
Find out how your country has ratified the convention (is there a children’s act that
includes the rights of the child?)
During the paediatric clerkship find out if there are children admitted because of child
abuse
Find out if there are organizations that address the rights of children in your country
Find out if your government has ways of addressing the problems of CEDC
Have a group discussion on possible interventions that would improve the welfare of
children in these situations
The child is defined as a person under 18 years of age. Though in some counties take
the cut off at 16 years. Often people talk of orphans and vulnerable children.
The definition of an orphan is a child under the age of 18 years who has lost a mother,
father, or both parents due to death. An orphan can be further defined as a double
orphan if the child has lost both parents, whereas a maternal orphan and paternal
orphan is defined as the loss of a mother or father respectively.
251
Vulnerability is even more difficult to define, as no single definition adequately captures
what constitutes a vulnerable child. Generally, a vulnerable child is any child who has
limited access to his or her basic needs. Thus, a child may be vulnerable but not an
orphan. Vulnerability is further defined according to three areas, namely, material,
emotional and social problems. Vulnerable children are children in situations listed
below.
The term refugee is applies to people who flee their country of origin and move to
another while displaced refers to people who are forcibly displaced within their country
TYPES OF CEDC
As seen below there are many situations that adversely affect children
Street children
Abandoned and neglected children
Orphans and destitute children
Abused and neglected children
Children living with disability (physical and mental)
Child prostitutes
Child labourers
Children of imprisoned mothers
Child brides
Child mothers
Drug addicts and traffickers
Children affected by armed conflict and political violence
Children in conflict with the law
Children living in informal settlements
Displacement due to natural disasters
All these groups undergo various forms of child abuse and exploitation.
Currently, the magnitude of the problem of CEDC warrants concern. Situational analysis
done in our region indicate that the problem is on the increase. This alarming state of
affairs and its upward trend calls for various national studies to give a clear picture.
However, from the research already done it is clear that rapid social economic (and
political changes in our countries) have contributed a great deal to this grave situation in
Africa.
CAUSES
Population explosion coupled with increased urbanization have been the major culprits
in bringing about CEDC. These two have adversely affected many a family giving rise to
large but poor families. Children from these families more often than not fall prey to child
prostitution, child labour, petty trade, drug abuse and trafficking. The girls are married
off at a very young age and often to much older men.
Traditional cultural values that acted as social support systems (for disadvantaged clan
members) and at the same time placed a high premium on children have been eroded
by modern lifestyles to the point whereby some children are regarded as liabilities.
Thus, we have children virtually living on the streets of our urban centres; children being
battered and killed by their next of kin are frequently reported in the media. Close
252
relatives do not move in, to assist their orphaned children, thus leaving them to fend for
themselves. Children who live without the guidance and protection of an adult care
givers are often more vulnerable and at risk of becoming victims of violence,
exploitation, trafficking, discrimination, early marriage and other abuses.
Some of African traditional cultural values give rise to child abuse, which leads to
children having babies when they are not physically and psychologically mature for the
responsibilities of being mothers. Taboo babies arising from traditional cultural practices
in some communities are unaccepted to their biological parents and are thus exposed to
all sorts of abuses especially abandonment.
Parents facing economic constraints may engage in illegal activities and my end up
serving custodial sentences. During which time they leave their children without support.
Mothers who go into prison may be allowed to go with their children who are aged
below four years. At least such mothers continue to take care those children but in
abnormal environment.
By and large, traditional land tenure and inheritance laws in many African cultures tend
not to provide for women to inherit land and property. So unmarried mothers looking for
neutral areas to settle end up in urban centres. Also involved in the migration to towns
are the youth – both young men and women seeking employment. More often than not,
the anticipated employment is not forthcoming and like the unmarried mothers often
engage in petty trades that cannot maintain their families. Their children are forced into
the streets, into petty trades as child labourers or even child prostitutes.
Whole families may be rendered landless due to land pressure and transactions. They
become squatters and their children lack proper basic amenities. Majority of them end
up as child labourers or members of other groups of CEDC.
Parents suffering from HIV/AIDS are now contributing to a large and increasing
numbers of CEDC. Unlike victims of other terminal illnesses, parents with HIV/AIDS
often die leaving their children not only without support but also stigmatized while others
may be HIV infected. An important emotional problem is space to grieve, as children
are often denied the grieving process, which is an important component of the
bereavement process.
Children with disabilities tend to be neglected and as result suffer from malnutrition,
poor health and are often victims of abuse and neglect.
253
Children also need services such as immunization services, access to oral rehydration,
clean water and sanitation and supplementation such as with vitamin A. These may not
be easily available close to refugee settlements. Because of poor sanitation diarrhoeal
diseases are prevalent
During armed conflict, girls and women are raped with the increasing danger of being
infected with HIV. Boys are recruited as soldiers. Separation, death of family members
creates emotional and psychological trauma.
APPROACH TO MANAGEMENT
Provide alternative families for children already in difficult circumstances (foster care an
adoption where necessary institutions)
Reduce and control the influx of children into the streets
Provide vocational training skills for CEDC
Strengthen Government and Non-governmental Organization (NGOs) existing
rehabilitation programmes.
Expand government and NGOs aid to poverty stricken families through state
maintenance and grants as well as professional services to poor parents attempting
business so as to strengthen their role in development thereby enabling them to support
their children. This would create a social safety net for vulnerable families and
vulnerable children
Amend and codify the existing statutes dealing with the rights of the child in every
country.
Carry out a National Survey to determine the magnitude of CEDC
Intensify Public awareness of the plight of CEDC
Encourage and support initiatives of communities and NGOs to establish alternative
educational centres (informal schools) for working children and children who cannot
afford conventional educational institutions.
STRATEGIES
Free universal primary school education has been introduced but still some vulnerable
children are not in school for varied reasons
Material support should also be provided to informal schools whenever they exist.
Support rehabilitation programmes initiated by NGOs; improve and expand the existing
governmental children’s institutions.
Organization of training workshops and seminars for Children Officers and NGO officials
dealing with children matters.
Development of advocacy for CEDC through the print and audio- visual media to step
up information in order to influence attitudes and behavioral patterns towards CEDC
e.g. encourage the well – to-do to sponsor or even foster and adopt from among the
CEDC: enhance awareness on handicapped children- their handling and possible
training. To create awareness on AIDS affected children and the need to care for them
within the community.
To organize a high level policy makers seminar for law enforcement agencies e.g.
police, magistrates, and lawyers to harmonize matters pertaining to children.
Establish rescue / rehabilitation centres in all major urban centres with prevalent CEDC.
Cary out national situational analysis to establish the magnitude of the problem of
CEDC.
254
Set up new and strengthen the already existing advisory committees on children and
young persons in every country.
Provide and promote makeshift schools and health centres for the refugee camps and
to avail on standby readily available supportive personnel.
The existing legal statutes on matters relating to child sexual abuse and child battering
to be reviewed and strengthened in every country.
The government to provide legal services and to subsidize costs incurred in
investigations involved in fostering and adoption services.
Strengthen and improve existing rehabilitative programmes for disabled children
A specific provision in the law to be made regarding child labour with a view to dealing
with their employers in formal sector e.g. Agriculture or house workers.
Mandate of parents marrying off their below 18 years old daughters to be removed –
thus absolutely no girl to be married before she is 18 years – to avoid child brides! A
provision also to be made for child mothers to be allowed to continue with education.
Relief agencies for refugee and displaced people
Several international bodies respond to natural and manmade disasters. These include
United Nations agencies like UNHCR, UNICEF, WFP, UNDP, and WHO; Red
Cross/Red Crescent, Save the Children and many others. It is a lot easier to respond to
natural disasters than conflicts as conflicts can last several years or even decades
making it difficult to sustain support.
There are established international regulations to safeguard the health of people in
affected situations. These are set particularly benefic children and women.
Responses to emergency situations include:
The immediate response by relief agencies is to save lives and protect basic health by
treating and/or preventing diseases. Other activities include:
Provision of shelter for the affected families
Provision household necessities such as clothing and blankets
Setting up curative services
Provision of food and setting up of feeding centres
Provision of clean water
Setting up sanitary facilities to prevent disease outbreaks
Registration of household members or displaced individuals
Setting up communication systems for tracing lost people and reuniting families
Services for children in emergencies
It is important to have special services for children as they are the most vulnerable.
Screening for and prompt treatment of illness is essential. Provision of adequate food
for all ages of children becomes crucial and especially those that have been separated
from or lost their parents. Counselling to allay anxiety, depression and fear has to be
provided as the trauma experience can excessive. For longer term schooling becomes
important. Even in these circumstances children need to be given the opportunity to be
children by providing love and a chance to play.
SHORT COMMINGS OF EXISTING PROGRAMMES
Non-governmental organizations make an invaluable contribution towards rehabilitation
of CEDC. There are many NGOs dealing with matters relating to children.
UNICEF is a major NGO in this area and is widely involved in funding of community
based rehabilitation programmes for CEDC. This NGO does a lot in terms of
coordinating activities for CEDC an area that have been neglected in the past. But in
general the following constraints are observed:
255
Lack of relevant and properly trained personnel to handle CEDC in both government
and NGOs at all levels.
Inadequate logistical support and lack of community – based preventive rehabilitation
programmes.
Lack of effective co-ordination amongst agencies working with target groups leading to
duplication of projects.
Overstretched facilities in terms of accommodation as well as in manpower and financial
resources.
Mixing of disciplines with protection cases in approved school due to lack of alternative
care for such cases.
Presence of undeserving cases in rehabilitative institutions meant for CEDC. This calls
for professional assessment of subjects prior to admission.
Lack of effective after –care following services foe graduates of rehabilitation centres.
CONCLUSIONS
It is crystal clear from the foregoing that CEDC is an existing problem.
It has identified both internationally and nationally. This calls foe effective policy
guidelines to safeguard the children’s rights with a view of arresting the existing
problems and as far as possible preventing the same from recurring.
The International Convention on the Rights of the Child is a blue print into solving the
problem of CEDC. The aims and objective of the Conventions can only be attained for
the African child in especially difficult circumstances by both the Government and
NGOs. This requires immediate Action.
Exercise 1
Stop to reflect on the situation of orphans and vulnerable children in your country. Form
small groups to discuss the following:
1. Who is an orphan?
2. Who are vulnerable children?
3. What are the causes associated with being orphaned and vulnerable?
Exercise 2
What are the health needs of children in refugee circumstances?
1. In small groups or individually itemize these health needs?
3. Plan to visit a refugee situation near you. What is different between your healthcare
system and that of refugee children?
What needs to improve in the service provision?
Exercise 3
256
REFERENCES
The Convention on the Rights of the child New York UNICEF 1989
Note: Website of the United Nations and other agencies mentioned in the chapter can
give invaluable references.
257
CHAPTER 21
INTRODUCTION
Health education is one of the core Primary Health Care strategies. It is a process of
helping change people’s behaviour in a way that will make their health and that of their
families and the community better. It is concerned with helping people take greater
responsibility for protection and promotion of their own health through provision of
correct information and modification of the existing inappropriate attitudes and practices
in respect to prevention, promotion, curative and rehabilitative care. It is also aimed at
promoting healthy lifestyles of the individual and the community. In the context of child
health, health education should aim at preventing common illnesses such as: diarrhoeal
diseases, malnutrition, acute respiratory infections, malaria, whooping cough, measles,
tuberculosis and acquired immune deficiency syndrome. Health workers therefore need
to develop proper attitudes, adequate knowledge and skills that will enable them provide
health education at various service delivery settings.
OBJECTIVES
At the end of this chapter the student will be able to:
LEARNING ACTVITIES
Participate in a group of health workers discussing basic health education skills needed
by all PHC workers and prepare a report.
Visit a child welfare clinic and determine the incidence of missed opportunities for health
education.
Prepare specific health education messages aimed at preventing diarrhoeal diseases,
malnutrition, and acute respiratory infections, malaria and measles.
Participate in a health education session in a child welfare centre.
Visit the national, regional or district health education unit and describe the different
communication and education media used for the promotion of health in your country.
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DETERMINANTS OF BEHAVIOURAL CHANGE:
The effects of health education efforts are strongly influenced by the individual’s cultural
beliefs, attitudes and values. Clear understanding of these attributes and their
consideration in preparing and giving of health education will have a positive influence
on the impact of the program. For instance, in most African communities children are
denied certain high protein and energy foods like eggs and fish because of cultural
taboos. A health education message that does not recognize this fact will most likely be
ignored by the mothers. However, knowledge of this taboo will facilitate the
development of the appropriate messages that could modify this practice positively and
lead to increased provision of these foods to children.
The doctor should play a leadership role in promoting community health development.
To play this role the doctor needs to develop skills in identifying the health needs and
resources of the community. This will assist in the development of educational
messages and strategies to respond to the community needs. He should be able to plan
and organize health education programmes that respond to the priority health needs in
his community. The doctor fulfils this leadership role through encouraging community
involvement, intersectoral collaboration and providing health education. He thus has a
responsibility for educating himself, other health workers and his patients on matters
relating to health development in his or her community.
COMMUNICATION SKILLS
Communication is the process of transferring messages and skills from the sender to
the receiver and from the receiver back to the sender. The receiver may be a person or
a group. If there is no response there is no communication.
It is the responsibility of the doctor or any other health educator to ensure that these
conditions are satisfied.
259
Communication skills that are important to the health worker include:
An effective educator should have clear concepts of educational objectives and a clear
statement of what the learner should be able to think, feel and do (behaviour,
observable activity) at the end of the learning period. The objectives are obtained from
the various tasks for solving the community health problems. Learning is the process
that results in relatively permanent change in behavior of the individual learner.
Learning is: controlled by the learner, affected by the total state of the learner, unique,
individual and the result of experience or repetition. The durability of cognitive and
behavioural change is proportional to the degree of active rather than passive
participation of the learner. Note the Chinese proverb “What I hear, I forget; what I see,
I recall; and what I do, I know”.
These may be presented in health facilities, through public radio, television and cinema.
This is a powerful method of health education as it combines entertainment and
education.
Lecture
Lecture is an easy way of providing a lot of information within a short period of time. It is
however not an efficient method in causing retention of the information. To accentuate
retention, a lecture must be interesting and to the point. It must be short as the attention
span of people wanes after about 30 minutes. The person delivering a lecture must
prepare and give real life examples or experiences. Allow time for discussion at the end.
The lecture should include the following:
260
An introduction explaining the importance of the topic to the students;
a statement of the objectives;
evaluation of what listeners already know;
learning activity such as answering questions;
presentation in a logical sequence;
repetition of the main points;
evaluation at the end and a summary.
Group Discussion
This is a good method because participants are actively involved. A group of 7-8 is
ideal. The educator serves as the moderator of the group discussion but does not
monopolise the discussion. He prepares the essential topic for discussion. An example
of a topic would be, “The role of exclusive breastfeeding in young infant nutrition.” A
good moderator introduces the topic; he then asks what people know before adding
what he thinks. The moderator will record the views of the members of the group
discussion and review them with the group at the end of the discussion.
Demonstration
This is a method used for teaching a skill. The skill is first described and then
demonstrated. The demonstration must be correct, visible and provide an explanation of
every step.
Practicals
Practice is the most effective method of helping acquire skills. The more the
opportunities for practice are offered the more the learner can improve his/her skills. All
the participants should practice and should be given feedback on how they are
performing the skill. This should include practice in speaking to individuals and groups
of people, demonstrating specific activities, and performing procedures. The clients
should be given the opportunity to practice under supervision.
Role Playing
This is an effective method of teaching attitudes, and communication skills. In this
method the learner acts different parts as if they are in a play, but they are only given
the outline and left to think out the rest. This could be illustrated by a role play activity
showing washing of hands before eating, use of the latrine, and breastfeeding as a
complimentary activity for preventing diarrhea.
Simulation
This is a method of providing the learner with some experience and practice on an
imitated thing before the actual task. For instance, the learner may use orange skin to
practice injections. Here the orange simulates the skin of a person.
COUNSELLING
There are ways of teaching people such that they can understand and be persuaded to
put what they learned into practice. The methods of health education are grouped as
personal and impersonal. While personal methods involve physical presence of the
261
counselor, the counselor is absent in the impersonal methods. The personal method
comprises counselling of an individual patient; and includes giving health education to a
small group. To be effective both the personal methods require establishment of
confidence and trust between the health worker and the individual or the group.
Counselling an Individual
Counselling an individual is the process of helping him to think clearly about his
problems, discover their causes and thus develop understanding of the causes. In the
process the counsellor:
This form of counselling is called non-directive. The decision arrived at is that of the
individual and not the counsellor.
Example: Providing feedback to the mother and praising her when she has learnt
something and when her baby is growing well improves learning. If the baby is not
growing, she is advised accordingly and sympathetically helped to reach a decision as
to what she can do to help the child acquire normal growth. Successful counselling
depends on the counsellor’s ability to establish a good rapport with the person being
counselled.
Group Counselling:
This is a method of helping a group of 10-15 people through discussing among
themselves to discover or define their health problems, to discover the most effective
solutions and to take action. In the discussion, the group members do offer each other
support for the appropriate behavior. The discussion is usually enjoyable with exchange
of experiences, enrichment of the individuals with ideas, and participation in decision-
making with other people.
The health worker first establishes rapport with creation of a relaxed friendly
atmosphere. He then introduces the discussion with a question, a film, a newspaper
cutting, a tape, a role play or a multiple choice question relevant to the issue. He also
summarizes from time to time and thinks of new directions the discussion should take.
During the discussion people are enabled to show their different values and attitudes, to
clarify their ideas and to make plans for a new course of action with the support of the
group. In this way, people can realize the motives behind their action. Some members
of the group may have already solved their problems and this would be helpful to those
still with a problem.
262
Impersonal Health Education Methods:
NB: Combination of personal and impersonal health education methods occurs when
the mass media messages reinforce individual counselling, when individual counselling
clarifies the mass media messages and when small group discussions use radio
messages, television programmes and newspapers as the focus or starter.
The learning needs of individual patients are assessed by encouraging people to talk
about themselves, what interests them and what they do not understand. The educators
listen carefully and observe the gestures as well as facial expressions. During the
interview the participants may raise some questions and express some doubts,
anxieties or satisfactions. These are optimum opportunities of offering health education
and should not be missed. Other opportunities for providing health education of an
individual patient are immediately after recovery from an illness or at discharge from a
health facility.
The health education needs of a community may be discovered from health service
information and by community diagnosis through: carrying out knowledge, attitude and
practice surveys, focus group discussions and behavioural observations.
HEALTH EDUCATION IN SCHOOLS
A very important component of the community is schools. Through health education,
teachers and school children can serve as agents of cultural change by changing the
content of instruction in line with changing knowledge, social needs and values. Health
education in school has the major goal of promoting health as a value and is a valuable
means of promoting healthy behaviour for generations. In schools, health education is
largely given formally in classes. Informal health education in schools may be given
during the contacts of the students and the health workers. The contacts represent
some teachable moments to be exploited.
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SELF EVALUATION QUESTIONS
How can you evaluate the achievements of a health education programme on control of
diarrhoeal diseases?
Explain what counselling is and list six qualities of a good counsellor.
Describe the reasons why some individuals do not immediately accept health education
messages.
Explain the role of informal leaders in health education.
REFERENCES
P Stanfield, N Bwibo Child health: A manual for medical and health workers in health
centres and rural hospitals. AMREF Rural Health Series 2005
264
CHAPTER 22
Kopano Mukelabai
income countries are 10 times more
Introduction likely to die before reaching their fifth
Globally the number of child deaths birthday than children living in
under five years of age has decreased by industrialized countries (1999 World
almost one quarter between 1990 and Health Report).
2006. In 2006 an estimated 9.6 million The major causes of child deaths are:
children died before reaching their 5th pneumonia, diarrhoea, measles, malaria
birthday, as compared to 13 million and malnutrition or often a combination
deaths in 1990. The reduction in under- of these conditions. HIV and AIDS has
five child morality has varied widely exacerbated under-five child morality,
throughout the world. Children in low to especially in countries in Africa South of
middle the Sahara. See Fig. 1.
Figures 1
Congenital
45% Under
Study
8% Preterm 61% HIV/AIDS
27% 5%
Measles
6%
Diarrhoea
27%
% of deaths due to maternal and neonatal Percent of deaths from this infection that
undernutrition is under study
% are due to the presence of undernutrition
265
Since the year 2000, the global Objectives:
community has been focused on At the end of this chapter a student will
achieving the Millennium Development be able to: - Define the IMCI strategy
Goals (MDGs). The MDG number 4 aims - Familiarize him/herself with IMCI
at reducing under-five child mortality in
adapted guidelines in his/her
the world by two thirds between 1990
and 2015. Neonatal mortality currently country
accounts for almost 40% of all children
- Identify the major causes of under
dying under five years of age. This
number is estimated to be 4 million five child mortality in his/her
neonatal deaths according to the
country.
UNICEF 2008 State of the World’s
Children. - Be conversant with the national
strategy to achieve the MDGs
Between 1980 and 2000 child death in
the first month of life declined by a number 4
quarter, while deaths between one month
- Assess a sick child, including
and five years of age declined by a third.
Affordable and cost effective strategies his/her immunization and
are now available in most countries to
nutritional status
prevent child deaths. These include
routine childhood immunization, oral - Classify the child’s illness, note
rehydration therapy, effective use of
the danger signs, and decide if the
antibiotics, regular use of insecticide
treated nets to prevent malaria, use of child needs urgent medical
newer anti-malaria drugs, breastfeeding
referral.
and prevention of mother to child
transmission of HIV and AIDS. - Give essential pre-referral
treatment (e.g., antibiotic, anti-
The IMCI strategy was developed by
WHO and UNICEF in collaboration with malarial, anti pyretic, or anti-
many agencies and institutions, and has
convulsant etc.)
now been adopted by many countries
and communities. The main objective of - Teach the mother how to
the strategy is to reduce child deaths and
administer treatment at home for
the frequency and severity of a child
illness and disability, hence contributing example an antibiotic, anti-
to improved child growth and
malarial etc.
development. The IMCI strategy
advocates for both preventive and - Advise the mother on proper
curative care and deals with aspects of
feeding practices and when to
child nutrition, immunization, disease
prevention and health promotion. The return to the health centres if the
IMCI guidelines have been adapted at
child becomes more sick.
country level to address the major
causes of child deaths and to provide - Do a follow up assessment and
health information to health workers,
give treatment for children coming
community health workers and to
families. for follow-up.
266
Infant and childhood mortality are Experience and scientific evidence show
sensitive indicators of inequity and that improvements in child health are not
poverty. It is no surprise to find that the necessarily dependant on the use of
children who are sophisticated and expensive
Improvements most commonly and technologies, but rather on effective
in child health are severely ill, are strategies that are based on a holistic
not necessarily
dependent on the use often those who are approach, are available to the majority of
of sophisticated and malnourished, and those in need, and which take into count
expensive those who are most the capacity and structure of health
technologies.
vulnerable. They systems, as well as traditions and beliefs
often belong to in the community.
underprivileged
populations of low income countries. Rationale for an evidence based
However, even within middle-income and syndromic approach to case
so called industrialized countries, there management
are often poor and neglected
communities; these are often neglected Many well-known prevention and
geographical areas where childhood treatment strategies have already proven
mortality remains high. Millions of effective for saving young lives.
children in these areas are often caught Childhood vaccinations have
in the vicious cycle of poverty and ill successfully reduced
health - poverty leads to ill health and ill deaths due to
health breeds poverty. measles. Oral A more integrated
rehydration therapy approach to
managing sick
Quality of care is another important has contributed to a children is needed
indicator of inequalities in child health. major reduction in to achieve better
Every day, millions of parents seek diarrhoeal deaths. outcomes.
Child health
health care for their children, taking them Effective antibiotics programmes need
to hospitals, health centers, pharmacies, have saved millions of to move beyond
doctors, and traditional healers. Surveys children with addressing single
disease to
reveal that many sick children are not pneumonia. Prompt addressing the
properly assessed and treated by these treatment of malaria overall health and
health providers, and that their parents has allowed more well-being of the
child.
are poorly advised. ³ At first-level health children to recover
facilities in low-income countries, and lead healthy lives.
diagnostic supports such as radiology Even modest
and laboratory services are minimal or improvements in breastfeeding practice
non-existent, and drugs and equipment, have reduced childhood deaths.
combined with an irregular flow of
patients, leave doctors at this level with While each of these interventions has
few opportunities to practice complicated shown great success, accumulating
clinical procedures. Instead, they often evidence approach to managing sick
rely on history and signs and symptoms children is needed to achieve better
to determine a course of management outcomes. Child health programmes
that makes the best use of available need to move beyond single disease to
resources. addressing the overall health and well-
being of the child. Because many
Providing quality care to sick children in children present with over lapping signs
these conditions is a serious challenge. and symptoms of disease, a single
Yet how can this situation be reversed? diagnosis can be difficult, and may not be
267
feasible or appropriate. This is especially resources are limited, the syndromic
true for first-level health facilities where approach is a more realistic and cost-
examinations involve few instruments, effective way to manage patients. Careful
little or no laboratory tests, and no and systematic assessment of common
instruments, little or laboratory tests, and symptoms and well-selected clinical
no X-ray. signs provides sufficient information to
guide rational and effective actions.
During the mid-1990s, the World Health
Organization (WHO), in collaboration An evidence-based syndromic approach
with UNICEF and many other agencies, can be used to determine the:
institutions and individuals, responded to Health problem (s) the child may
this challenge by developing a strategy
have
known as the Integrated Management of
Childhood Illness (IMCI). Although the Severity of the child’s condition;
major reason for developing the ICMI
Actions that can be taken care for
strategy stemmed from the needs of
curative care, the strategy also that child (e.g. refer the child
addresses aspects of nutrition,
immediately, manage with
immunization, and other important
elements of disease prevention and available resources, or manage at
health promotion. The objectives of the
home).
strategy are to reduce death and the
frequency and severity of illness and
disability, and to
Careful and contribute to
systematic Fig. 2
assessment of
improved growth
common symptoms and development. In addition, ICMI promotes:
and well-selected
specific clinical signs
The ICMI clinical
provide sufficient Adjustment of the curative
information to guide guidelines target
rational and children less than 5 interventions to the capacity and
effective actions.
years old - the age
functions of the health system;
group that bears
the highest burden and
of deaths from common childhood
Active involvement of family
diseases. (Figure 1).
member and the community in the
The guidelines take an evidence-based,
health care process.
syndromic approach to case
management that supports the rational, Parents, if correctly informed and
effective and affordable use of drugs and counselled, can play an important role in
diagnostic tools. Evidence-based improving the health by following the
medicine stresses the importance of advice given by a health care provider,
evaluation of evidence from clinical by applying appropriate feeding
research and cautions against use of practices and by bringing sick children to
intuitions, unsystematic clinical a doctor as soon as symptoms arise. A
experience, and untested critical example of the need for timely
pathophysiologic reasoning for medical care is in Africa; here approximately 80%
decision-making. In situations where percent of childhood deaths occur at
laboratory supports and clinical
268
Main components of IMCI
269
“pink” suggests hospital referral or Make the IMCI implementation
admission, “yellow” indicates feasible
initiation of treatment, “green”
through the health system and by
indicates calls for home treatment.
families caring for their children at
The ICMI guidelines address most, but home.
not all, of the major reasons a sick
child is brought to a clinic.
A child returning with chronic Adaption of the ICMI guidelines normally
problems or less common illness may
require special care. The guidelines is co-ordinated by national health
do not describe the management regulating body (e.g.
of trauma or other acute emergencies
due to accidents or injuries. Ministry of Health) and incorporates
decisions carefully made by national
IMCI management procedures use a
limited number of essential health experts.
drugs and encourage active For this reason, some clinical signs and
participation of caretakers in the details of clinical procedures described
treatment of children.
below may differ from those used in a
An essential component of the IMCI
guidelines is the counselling of particular country. The principles used for
caretaker about home management, management of sick children, however,
including counselling about feeding,
are fully applicable in all situations.
fluids and when
to return to a health facility.
The IMCI case management process
Adapting the guidelines to a country’s The case management of a sick child
situation brought to a first-level health facility
includes a number of important elements.
The underlying principles of the IMCI
guidelines are constant. However, in Outpatient health facility
each country the IMCI clinical guidelines Assessment
should be adapted to;
Classification treatment or counselling
Cover the most serious childhood of the
illness typically seen at first-level child’s caretaker (|depending on the
health facilities; classification(s) Identified);
Follow-up care
Make the guidelines congruent with
national treatment guidelines and Referral health facility
other policies; and Emergency triage assessment
and treatment (ETAT)’
270
Diagnosis, treatment and monitoring and importance. Therefore, The IMCI
guidelines recommend case
of patient progress.
management procedures based on two
age categories:
Appropriate home management Children age 2 months up to 5
Teaching the mother or other years
caretaker to give oral drugs and treat Young infants age 1 week up to 2
local infections at home; months
Counselling the mother or other
caretaker about food (feeding
recommendations, feeding problems,);
fluids; when to return to the health
facility; and her own health.
271
Key family practices (2)
272
Fgure 3. IMCI management in the health facility, first-level referral facility and at
home for the sick child from age 2 months up to 5 years
273
Outpatient management of children
Age 2 months up to 5 years
Other problems
A sick child brought
It is critical to communicate effectively to an outpatient facility may have signs
that clearly indicate a specific problem.
with the child’s mother or caretaker.
Good communication techniques and For example, a child may present with
chest in drawing and cyanosis, which
an integrated assessment are
required to ensure that common indicate severe pneumonia. However,
problems or signs of disease or some children may present with serious,
malnutrition are not overlooked. Using non-specific signs called “general danger
274
signs” that do not point to a particular
diagnosis. For example, a child who is
lethargic or unconscious may have The child vomits everything. The
meningitis, severe pneumonia, cerebral vomiting
malaria or another severe disease. Great It may be a sign of serious illness, but it
care should be taken to ensure that is also important to note because such a
these general danger signs are not child will not be able to take medication
overlooked because they suggest that a or fluids for rehydration.
child is severely ill and needs urgent
attention. If a child has one or more of these
signs, she/he must be considered
The following danger signs should be seriously ill and will almost always need
routinely checked in all children. referral. In order to start treatment for
severe illnesses without delay, the child
The child has had convulsions should be quickly assessed for the most
during the important causes of serious illness and
present illness. Convulsions may be death – acute respiratory infection (ARI),
the result of fever. In this instance, diarrhoea, and fever (especially
they do little harm beyond frightening associated with malaria and measles). A
the mother. On the other hand, rapid assessment of nutritional status is
convulsions may be associated with also essential, as malnutrition is another
meningitis, cerebral malaria or other main cause of death.
life-threatening conditions. All children
who have had convulsions during the Checking main symptoms
present illness should be considered
seriously ill. After checking for general danger signs,
the health care provider must check for
The child is unconscious or main symptoms. The generic IMCI
lethargic. An unconscious child is clinical guidelines suggest the following
likely to be seriously ill. A lethargic four: (1) cough or difficult breathing; (2)
diarrhoea; (3) fever; and (4) ear problems
child, who is awake but does not take
any notice of his or her surroundings The first three symptoms are included
or does not respond normally to because they often result in death. Ear
sounds or movement, may also be problems are included because they are
very sick. These signs may be considered one of the main causes of
childhood disability in low-and middle –
associated with many conditions.
income countries.
The child is unable to drink or Child presenting with cough or difficult
breastfeed. breathing should first be assessed for
A child may be unable to drink either general danger signs. This child may
because she/he is too weak or have pneumonia or another severe
because she/he cannot swallow. Do respiratory infection. After checking for
not rely completely on the mother’s danger signs, it is essential to ask the
evidence for this, but observe while child’s caretaker about this main
she tries to breastfeed or to give symptom.
the child something to drink.
275
Clinical assessment Note: The specificity of respiratory rate
for detecting pneumonia among the
Three key clinical signs are used to population. In areas with high levels of
assess a sick child with cough or difficult viral pneumonia, respiratory rate has
breathing: relatively modest specificity.
Nevertheless, even if the use of
Respiratory rate, which distinguishes respiratory rate leads to some
children who have pneumonia from overtreatment, this will still be small
those who do not; compared with the current use of
antibiotics for all children with an ARI, as
Lower chest wall indrawing, which occurs in many clinics.
indicates severe pneumonia; and
Lower chest wall indrawing, defined as
the inward movement of the bony
structure of the chest wall with
Stridor, which indicates those with inspiration, is a useful indicator of severe
severe pneumonia. It is more specific than
pneumonia which requires hospital “intercostal indrawing,” which concerns
admission. the soft tissue between the ribs without
involvement of the bony structure of the
No single clinical sign has a better chest wall.8 Chest indrawing should only
combination of sensitivity and specificity be considered present if it is consistently
to detect pneumonia in children under 5 present in a calm child. Agitation, a
than respiratory rate, specifically fast blocked nose or breastfeeding can all
breathing. Even auscultation by an cause temporary chest indrawing.
expert is less sensitive as a single sign.
Stridor is a harsh noise made when the
Cut –off rates for fast breathing (the point child inhales (breathes in). Children who
at which fast breathing is considered to have stridor when calm have a
be fast) depend on the child’s age. substantial risk of obstruction and should
Normal breathing rates are higher in be referred. Some children with mild
children age 2 months up to 12 months croup have stridor only when crying or
than in children age 12 months up to 5 agitated. This should not be the basis for
years. indiscriminate referral. Sometimes a
wheezing noise is heard when the child
Child’s age Cut-off rate fast exhales (breathes out). This is not
breathing stridor. A Wheezing sound is most often
associated with asthma. Experience
2 months up to 12 months 50 breaths
suggests that even where asthma rates
per minute or
are high, mortality from asthma is
more
relatively uncommon. In some cases,
12 months up to 5 years 40 breaths especially when a child has wheezing
per minute or when exhaling, the final decision on
more presence or absence of fast breathing
can be made after a test with a rapid
acting bronchodilator (if available). At this
level, no distinction is made between
276
children with bronchiolitis and those with detects about 80 percent of children
pneumonia. with pneumonia who need antibiotic
treatment. Treatment based on this
classification has been shown to
Classification of cough or difficult reduce mortality.
breathing
Fast breathing
Based on a combination of the above
clinical signs, children presenting with
cough or difficult breathing can be Those who simply have a cough
classified into three categories: or cold and do not require antibiotics.
Such children may require a safe
Those who require referral for
remedy to a relieve cough. A child
possible severe pneumonia or very
with cough and cold normally
severe disease.
improves in one or two weeks.
However, a child with chronic cough
This group includes children with any
(more than 30 days) needs to be
general danger sign, or lower chest
further assessed (and, if needed,
indrawing or stridor when calm.
referred) to exclude tuberculosis,
Children with severe pneumonia or
asthma, whooping cough or another
very severe disease most likely will
problem.
have invasive bacterial organisms
and diseases that may be life-
threatening. This warrants the use of NO
No signs of
injectable antibiotics. pneumonia or very PNEUMONIA:
severe disease COUGH OR
COLD
Any general SEVERE
Diarrhoea
danger sign or PNEUMONIA
OR A child presenting with diarrhoea should
Chest
first be assessed for general danger
indrawing VERY SEVERE signs and the child’s caretaker should be
DISEASE asked if the child has cough or difficult
Stridor in
breathing.
calm child
Diarrhoea is the nest symptom that
should be routinely checked in every
Those who require antibiotics as child brought to the clinic. A child with
outpatient diarrhoea may have three potentially
because they are highly likely to have lethal conditions: (1) acute watery
bacterial pneumonia. diarrhoea (including cholera); (2)
dysentery (bloody diarrhoea); and (3)
This group includes all children with persistent diarrhoea (diarrhoea that lasts
fast respiratory rate for age. Fast more than 14 days). All children with
breathing, as defined by WHO, diarrhoea; (a) signs of dehydration (b)
277
how long the child has had diarrhoea; to drink more, s/he does not have the
and (c) blood in the stool to determine if sign “drinking eagerly, thirsty.”
the child has dysentery.
Elasticity of skin. Check elasticity using
Clinical assessment the skin pinch test. When released, the
sin pinch goes back either very slowly
All children with diarrhoea should be longer than 2 seconds), or slowly (skin
checked to determine the duration of stays up even for a brief instant), or
diarrhoea, if blood is present in the stool immediately. In a child with marasmus
and if dehydration is present. A number (severe malnutrition), the skin may go
of clinical signs are used to determine back slowly even if the child is not
the level of dehydration. dehydrated. In an overweight child, or a
child with oedema, the skin may go back
Child’s general condition. Depending immediately even if the child is
on the degree of dehydration, a child with dehydrated.
diarrhoea may be lethargic or
unconscious (this is also a general Standard procedures for skin pinch test
Locate the area on the child’s abdomen
danger sign) or look restless/irritable. halfway between the umbilicus and the
Only children who cannot be consoled side of the abdomen; then pinch the skin
and calmed should be considered using the thumb and first finger.
restless or irritable. The hand should be placed so that when
the skin is pinched, the fold of skin will be
Sunken eyes. The eyes of a dehydrated in a line up and down the child’s body and
child may look sunken. In a severely not across the child’s body
malnourished child who is visibly wasted It is important to firmly pick up all of the
(that is, who has marasmus), the eyes layers of skin and the tissue under them
may always look sunken, even if the child for one second then release it.
is not dehydrated. Even though the sign
“sunken eyes” is less reliable in a visibly
wasted child, it can still be used to After the child is assessed for
classify the child’s dehydration. dehydration, the caretaker of child with
diarrhoea should be asked how long the
Child’s reaction when offered to drink.
child has had diarrhoea and if there is
A child is not able to drink if s/he is not
blood in the stool. This will allow
able to take fluid in his/her mouth and
identification of children with persistent
swallow it. For example, a child may not
diarrhoea and dysentery.
be able to drink because s/he is lethargic
or unconscious. A child is drinking poorly
Classification of dehydration
if the child is weak and cannot drink
without help. S/he may be able to
Based on combination of the above
swallow only if fluid is put in his/her
clinical signs, children presenting with
mouth. A child has the sign drinking
diarrhoea are classified into three
eagerly, thirty if it is clear that the child
categories:
wants to drink. Notice if you offer him/her
water. When the water tank is taken Those who have severe dehydration
away, sees if the child takes a drink only
and who require immediate IV
which encouragement and does not want
infusion, nasogastric or oral fluid
replacement according to the
278
WHO treatment guidelines described dehydration, which is a descriptive term
in Plan C (see figure 4 under used in most paediatric textbooks.
treatment procedures).
285
also be referred to hospital for
Tender swelling behind the ear. The
treatment.
most serious complication of an ear
infection is a deep infection in the
mastoid bone. It usually manifests with
MEASLES WITH tender swelling behind one of the child’s
Pus ears. In infants, this tender swelling also
draining EYE OR MOUTH
may be above the ear. When both
from the COMPLICATIONS tenderness and swelling are present, the
eye or sign is considered positive and should
Mouth not be mistaken for swollen lymph nodes.
ulcers
Ear pain. In the early stages of acute
otitis media, a child may have ear pain,
If no signs of measles complications which usually causes the child to become
have been found after a complete irritable and rub the ear frequently.
examination, a child is classified as
having Measles. These children can Ear discharge or pus. This is another
be effectively and safely managed at important sign of an ear infection. When
a mother reports an ear discharge, the
home with vitamin A treatment.
health care provider should check for
pus drainage from the ears and find out
how long the discharge has been
MEASLES
Measles now or present.
within Classification of ear problems
the last three
Based on the simple clinical signs above,
months the child’s condition can be classified in
the following ways:
Ear problems are the next condition that
Children presenting with tenderness
should be checked in all children brought
to the outpatient health facility. A child and swelling of the mastoid bone are
presenting with an ear problem should classified as having mastoiditis and
first be assessed for general danger should be referred to the hospital for
signs, cough or difficult breathing, treatment. Before referral, these
diarrhea and fever. A child with an ear children first should receive a dose of
problem may have an ear infection. antibiotic and a single dose of
Although ear infections rarely cause
paracetamol for pain.
death, they are the main cause of
deafness in low-income areas, which in
turn leads to learning problems.
Tender MASTOIDITIS
welling
behind the
Clinical assessment ear
When otoscopy is not available, look for
the following simple clinical signs:
286
Children with ear pain or ear
discharge (or pus) for fewer than 14 After assessing for general danger signs
days are classified as having acute and the four main symptoms, all
children should be assessed for
ear infection \and should be treated
malnutrition and anaemia. There are two
for five days with the same first-line main reasons for routine assessment of
antibiotic as for pneumonia. nutritional status in sick children: (1) to
identify children with severe malnutrition
who are at increased risk of mortality
and need urgent referral to provide
active treatment; and (2) to identify
children with sub-optimal growth
Ear discharge for resulting from ongoing deficits in dietary
fewer than 14 days ACUTE EAR
intake plus repeated episodes of
INFECTION
or infection (stunting), and who may benefit
from nutritional counselling and
Ear pain resolution of feeding problems. All
children also should be assessed for
anaemia.
If there is ear discharge (or pus) for
more than 14 days, the child’s
classification is chronic ear
infection. Dry the ear by wicking. Clinical assessment
Generally, antibiotics are not
Because reliable height boards are
recommended because they are
difficult to find in most outpatient health
expensive and their efficacy is not facilities, nutritional status should be
proven. assessed by looking and feeling for
following clinical signs:
287
Weight for age. When height boards are signs included in IMCI guidelines, it can
not available in outpatient settings, a allow doctors to identify sick children with
weight for age indicator (a standard severe anaemia often caused by malaria
WHO or national growth chart) helps to infection. Where feasible, the specificity
identify children with low (Z score less of anaemia diagnosis may be greatly
than-2) or very low (Z score less than-3) increased by using a simple laboratory
weight for age who are at increased risk test (e.g., the HB test).
of infection and poor growth and
development.
All children less than 2 years old and all children classified as anaemia or low (or
very low) weight need to be assessed for feeding.
The immunization status of every child brought to a health facility should be checked.
Illness is not a contraindication to immunization. In practice sick children may even be in
more need of protection provided by immunization than well children. A vaccine’s ability
to protect is not diminished in sick children.
289
As a rule there are only four situations when immunization is relatively contra-indicated:
- Children being referred urgently to hospital should not be immunized. There is no
medical contraindication, but if a very sick child dies on the way, the vaccine may
be incorrectly blamed;
- Live vaccines (BCG, measles, polio, yellow fever) should not be given to children
with immunodeficiency diseases, or to children who are immunosuppressed due
to malignant disease, or therapy with immunosuppressive agents or irradiation.
Children suspected to be HIV positive who are currently asymptomatic should
receive all recommended vaccinations for children.
- DPT2 / DPT3 should not be given to children who had convulsions or shock
within three days of a previous dose of DPT. Instead DT can be given.
- DPT should not be given to children with recurrent convulsions or active
neurologic disease. DT can be administered instead.
-
Referral of children age 2 months up to 5 years
All infants and children with a severe classification (pink) are referred to a hospital as
soon as assessment is completed and necessary pre-referral treatment is administered.
Successful referral of severely sick children to hospital depends on effective counseling
of the caretaker. If she does not accept referral, available options (to treat the child by
repeated clinic or home visits) should be considered. If the caretaker accepts referral,
she should be given a short clear referral note, and should get information on what to do
during referral transport, especially if the hospital is far away. The referral note must
indicate the name and age of the child, date and time of referral, description of child’s
illness, reason for referral, and treatment given so far.
Urgent pre- referral treatment for children age 2 months up to 5 years (see Figure
4)
Appropriate antibiotic
Quinine (for severe malaria )
Vitamin A
Prevention of hypoglycemia with breast milk or sugar water
Oral antimalarial
Paracetamol for high fever (38.5⁰C or above) or pain
Tetracycline eye ointment (if clouding of the cornea or pus draining from eye)
ORS solution so that the mother can give frequent sips on the way to the hospital
Note
The first four treatments above are urgent because they can prevent serious
consequences such as progression of bacterial meningitis or cerebral malaria, corneal
rupture due to lack of vitamin A, or brain damage from low blood sugar. The other listed
treatments are also important to prevent worsening of the illness.
Non-urgent treatments, e.g. wicking a draining ear or providing oral iron treatment,
should be deferred to avoid delaying referral or confusing the caretaker. If a child does
290
not need urgent referral, check to see if the child needs non-urgent referral for further
assessment; for example, for a cough that has lasted more than 30 days, or for fever
that has lasted five days or more. These referrals are not as urgent, and other
necessary treatments may be done before transporting for referral.
Oral Drugs
Always start with a first line drug. These are usually less expensive, more readily
available in a given country, and easier to administer. Given a second line drug (which
are usually more expensive and more difficult to obtain) only if a first line drug is not
available, or if the child’s illness does not respond to the first line drug. The health care
provider also needs to teach the mother or caretaker how to give oral drugs at home.
Oral antibiotics: The IMCI chart shows how many days and how many times each
day to give the antibiotic. Most antibiotics should be given for five days. The
number of times to give the antibiotic each day varies (two, three or four times per
day) determine the correct does of antibiotic based on the child’s weight. If the
child’s weight is not available, use the child’s age. Always check if the same
antibiotic can be used for treatment of different classifications a child may have. For
example, the same antibiotic could be used to treat both pneumonia and acute ear
infection.
Oral antimalarials: Oral antimalarials vary by country. Consult recommended
treatment schedules for malaria for your country.
Figure 4. Urgent pre-referral treatments for the sick child from age 2
months to 5 years.
CLASSIFICATION Treatment
For all children before referral :
Prevent low blood sugar by giving breast milk or sugar water.
DANGER SIGN – If the child convulsing give diazepam (10mg/2ml solution) in
CONVULSIONS dose 0.1 ml/kg or paraldehyde in dose 0.3-0.4ml/kg rectally; if
convulsions continue after 10 minutes, give a second dose of
diazepam rectally.
291
SEVERE PNEUMONIA Give first dose of an appropriate antibiotic. Two recommended
OR VERY SEVERE choices are cotrimoxazole and amoxicillin. If the child cannot
DISEASE take an oral antibiotic (children in shock or those who are
vomiting incessantly or are unconscious), give the first dose of
intramuscular chloramphenicol (40mg/kg). options for an
intramuscular antibiotic for pre-referral used include
benzylpenicillin and ceftriaxone.
VERY SEVERE FEBRILE Give one dose of paracetamol for high fever (38.5° C or
DISEASE above).
Give first dose of intramuscular quinine for severe malaria
unless no malaria risk.
Give first dose of an appropriate antibiotic.
292
Note: in areas where cholera cannot be excluded for patients
less than 2 years old with severe dehydration, antibiotics are
recommended. Two recommended choices are cotrimoxazole
and tetracycline.
SEVERE PERSISTENT If there is no other severe classification, treat dehydration
DIARRHOEA before referral using WHO Treatment plan B for some
dehydration and Plan C for severe dehydration. Then refer to
hospital.
MASTOIDITIS Give first dose of an appropriate antibiotic. Two recommended
choices are cotrimoxazole and amoxicillin. If the child cannot
take an oral antibiotic (children in shock or those who are
vomiting incessantly or who are unconscious), give the first
dose of intramuscular chloramphenicol (40mg/kg). Options for
an intramuscular antibiotic for pre-referral use include
benzylpenicillin and ceftriaxone.
Figure 5. Treatment in the outpatient health facility of the sick child from age 2
months up to 5 years
CLASSIFICATION
PNEUMONIA TREATMENT
NO PNEUMONIA –COUGH OR COLD Soothe the throat and relieve the cough
with a safe
remedy.
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Fluids should be given as soon as diarrhoea starts,
the child should take as much as s/he wants.
Correct home therapy can prevent dehydration in
many cases. ORS may be used at home to prevent
dehydration. However, other fluids that are
commonly available in the home may be less costly,
more convenient and almost as effective. Most
fluids that a child normally takes can also be used
for home therapy especially when given with food.
PERSISTENT DIARRHOEA
Encourage the mother to continue breastfeeding.
If yoghurt is available, give it in place of any animal
milk usually taken by the child; yoghurt contains
less lactose and is better tolerated. If animal milk
must be given, limit to 50ml/kg per day; greater
amounts may aggravate the diarrhoea.
If milk is given, mix it with the child’s cereal and do not
dilute the milk. At least half of the child’s energy
intake should come from foods other than milk or milk
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products. Food that are hyperosmolar (these are
usually foods or drinks made very sweet by the
addition of sucrose, such as soft drinks or commercial
fruit drinks) should be avoided. They can worsen
diarrhea. Food needs to be given in frequent, small
meals, at least six times a day. All children with
persistent diarrhea receive supplementary
multivitamins and minerals (copper, iron, magnesium,
zinc) each day for two weeks.
DYSENTERY
The four key elements of
dysentery treatment are:
Antibiotics
Fluids
Feeding
Follow-up
FEVER- MALARIA UNLIKELY Give one dose of paracetamol for high fever (38.5º
C or above).
POSSIBLEBACTERIAL INFECTION Treat other obvious causes of fever.
UNCOMPLICATED FEVER
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MEASLES WITH OR Give first dose of Vitamin A. If clouding of cornea
or pus draining from the eye, apply tetracycline eye
ointment
MOUTH COMPLICATIONS If mouth ulcers, treat with gentian violet.
ANAEMIA OR LOW WEIGHT Assess the child’s feeding and counsel the mother
according on feeding. If pallor is present: give iron;
give oral anti malarial if high malaria risk. In areas
where hookworm or whipworm is a problem, give
mebendazole if the child is 2 years or older and has
not had a dose in the previous six months.
NO ANAEMIA NOT LOW WEIGHT If the child is less than 2 years old, assess the
child’s feeding and counsel the mother accordingly on
feeding.
Paracetamol. If a child has a high fever, give one dose of paracetamol in the
clinic. If the child has ear pain, give the mother enough paracetamol for one day, that
is, four doses. Tell her to give one dose every six hours or until the ear pain is gone.
Iron. A child with anaemia needs iron. Give syrup to the child under 12
months of age. If the child is 12 months or older, give iron tablets. Give the mother
enough iron for 14 days. Tell her to give her child one dose daily for those 14 days.
Ask her to return for more iron in 14 days. Also tell her that the iron may make the
child’s stools black.
Note: If a child with some pallor is receiving the antimalarial treatment using
sulfadoxine- pyrimethamine (Fansidar), do not give iron/folate tablets until a follow-up
visit in two weeks. The iron/folate may interfere with the action of the sulfadoxine-
pyrimethamine that contains antifolate drugs. If an iron syrup does not contain folate,
a child can be given an iron syrup with sulfadoxine pyrimethamine. Consult
recommended treatment charts for malaria in your country
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Antihelminth drug. If hookworm or whipworm is a problem in the area, an
anaemic child who is 2 years of age or older may need mebendazole. These
infections contribute to anaemia because of iron loss through intestinal bleeding.
Give 500 mg of mebendazole as a single dose in the clinic.
Safe remedy for cough and cold. There is no evidence that commercial cough
and cold remedies are any more effective than simple home remedies in relieving a
cough
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The steps to good communication were listed earlier. Some advice is simple; other
advice requires teaching the mother or caretaker how to do a task. When you teach a
mother how to treat a child, use three basic teaching steps: give information; show an
example; let her practice. When teaching the mother or caretaker: (1) use words that
s/he understands; (2) use teaching aids that are familiar; (3) give feedback when
s/he practices, praise what was done well and make corrections; (4) allow more
practice, if needed; and (5) encourage the mother or caretaker to ask questions and
the answer all questions. Finally, it is important to check the mother’s or caretaker’s
understanding.
The content of the actual advice will depend on the child’s condition and classifications.
Below are
essential elements that should be considered when counseling a mother or caretaker:
Advise to continue feeding and increase fluids
during illness;
Teach how to give oral drugs or to treat local
infection;
Counsel to solve feeding problems (if any);
Advise when to return.
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Specific feeding recommendations should be provided for children with persistent
diarrhoea. Feeding counselling relevant to identified feeding problems is described in
the IMCI national feeding recommendations.
Advise when to return: Every mother or caretaker who is taking a sick child home
needs to be advised about when to return to a health facility. The health care provider
should (a) teach signs that mean to return immediately for further care; (b) advise when
to return for a follow-ups visit; and (c) schedule the next well-child or immunization visit.
The table below lists the specific times to advise a mother or caretaker to return to a
health facility.
A. IMMEDIATELY
Develops a fever
Pneumonia 2 days
Dysentery
Pallor 14 days
Low (very low) weight for age 30 days
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NEXT WELL CHILD VISIT
C. NEXT WELL-CHILD VISIT
Advise when to return for the next immunization according to immunization schedule.
FOLLOW-UP CARE
Some sick children will need to return for follow-up care. At a follow-up visit, see if the
child is improving on the drug or other treatment that was prescribed. Some children
may not respond to a particular antibiotic or antimalarial, and may need to try a
second-line drug. Children with persistent diarrhoea also need follow-up to be sure
that the diarrhoea has stopped. Children with fever or eye infection need to be seen if
they are not improving. Follow-up is especially important for children with a feeding
problem to ensure they are being fed adequately and are gaining weight.
When a child comes for follow-up of an illness, ask the mother or caretaker if the child
has developed any new problems. If she answers yes, the child requires a full
assessment: check for general danger signs and assess all the main symptoms and
the child’s nutritional status.
If the child does not have a new problem, us the IMCI follow-ups instructions for each
specific problems:
Assess the child according to the instructions;
Use the information about the child’s signs to select the appropriate treatment;
Give the treatment.
Note: If a child who comes for follow-up has several problems and is getting worse, or
returns repeatedly with chronic problems that do not respond to treatment, the child
should be referred to a hospital.
The IMCI charts contain detailed instructions on how to conduct follow-ups visits for
different diseases. Follow-up visits are recommended for sick children classified as
having:
Dysentery
Malaria, if fever persists
Fever – Malaria Unlikely, if fever persists
Measles with eye or mouth complications
Persistent diarrhoea
Acute ear infection
Feeding problem
Pallor
Very low weight for age
Any other illness, if not improving
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Outpatient management of young infants age 1 week up to 2 months.
It is important to remember that the guidelines above are not used for a sick new –born
who is less than 1 week old. In the first week of life, new born infants are often sick
from conditions that related to labour and delivery, or have conditions that require
special management. New–born may be suffering from asphyxia, sepsis from
premature ruptured membranes or other intrauterine infection, or birth trauma. Or they
may have trouble breathing due to immature lungs. Jaundice also requires special
management in the first week of life.
While the signs of pneumonia and other serious bacterial infections cannot be easily
distinguished in this age group, it s recommended that all sick young infants be
assessed first for signs of possible bacterial infection.
Clinical Assessment
Many clinical signs point to possible bacterial infection in sick young infants. The most
informative and easy to check signs are;
Convulsions (as part of the current illness). Assess the same as for older children.
302
Fast Breathing. Young infants usually breathe faster than older children do. The
breathing rate of a healthy young infant is commonly more than 50 breaths per minute.
Therefore, 60 breaths per minute is the cut off rate to identify fast breathing in this age
group. If the count is 60 breaths or more, the count should be repeated, because the
breathing rate of a young infant is often irregular. The young infant will occasionally
stop breathing for a few seconds, followed by a period of faster breathing. If the second
count is also 60 breaths or more the young infant has fast breathing.
Severe Chest Indrawing . Mild chest indrawing is normal in a young infant because of
softness of the chest wall. Severe chest indrawing is very deep and easy to see. It is a
sign of pneumonia or other serious bacterial infection in a young infant.
Nasal Flaring . (When an infant breaths in) and grunting (when an infant breathes out)
are an indication of troubled breathing and possible pneumonia.
A bulging Fontanel (when an infant is not crying), Skin pustules, umbilical redness or
pus draining from the ear are other signs that indicate possible bacterial infection.
A sick young infant with possible serious bacterial infection is one who has any of
the following signs: fast breathing, sever chest indrawing, grunting, nasal flaring,
bulging fontanel, convulsions, fever, hypothermia, many or sever skin pustules,
umbilical redness extending to the skin, pus draining from the ear, lethargy,
unconsciousness, or less than normal movement. This infant should be referred
urgently to the hospital after being given intramuscular benzyl penicillin (or
ampicillin) plus gentamicin, treatment to prevent hypoglycemia, and advice to the
mother on keeping the young infant warm
Convulsions or
Fast breathing or
Sever chest indrawing
or
Nasal flaring or
Grunting or POSSIBLE
Bulging fontanelle or BACTERIAL
Pus draining ear or INFECTION
303
Umbilical redness
extending to skin or
Fever or hypothermia
Many or sever skin
pustules or
Lethargy or
unconsciousness or
Less than normal
movement
A sick young infant with local bacterial infection is one who has only a few skin
pustules or an umbilicus that is red or draining pus, but without redness extending to
skin. This infant may be treated at home with oral antibiotics but should be seen in
follow up in two days.
Red umbilicus
or draining pus LOCAL
or BACTERIAL
Skin pustules INFECTION
Diarrhoea
All sick young infants should be checked for diarrhoea.
Clinical assessment
Determine weight for age. Assess the same as for older children.
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Oral drugs
Figure 6. Urgent pre-referral treatments for sick young infants age 1 week up to 2
months
CLASSIFICATION
TREATMENT
CONVULSIONS
If the child is convulsing, give diazepam (10 mg/2 ml
solution) in
dose 0.1 ml/kg or paraldehyde in dose 0.3 – 0.4 ml/kg
rectally; if convulsions continue after 10 minutes, give a
second dose of diazepam rectally. Use Phenobarbital (200
mg/ml solution) in dose of 20 mg/kg to control convulsions in
infants under 2 weeks of age.
307
POSSIBLE SERIOUS BACTERIAL Give first dose of intramuscular antibiotics
the recommended choice are Gentamycin
(2.5mg/kg) plus Benzylpenicillin(50,000
units per kg) or ceftriaxone OR cefotaxime
INFECTIONS AND/OR NOT ABLE
TO FEED-POSSIBLE SERIOUS
BACTERIAL INFECTIONS
______________________________________________________________________
SEVERE DEHYDRATION See recommendations for older children
Figure 4
.
DYSENTRY AND/OR Se recommendations for older children
Figure 4
SEVERE PERSISTENT DIARRHOEA
---------------------------------------------------------------------------------------------------------------------
CLASSIFICATION
TREATMENT
Local bacterial infection
Give an appropriate oral antibiotic. The
recommended choices
are cotrimoxazole and amoxicillin
SOME DEHYDRATION
See recommendations for older children, figure
5
NO DEHYDRATION
See recommendations for older
children, figure 5
308
FEEDING PROBLEM OR LOW WEIGHT
Give appropriate feeding advice.
There are three types of local infections in a sick young infant that a caretaker
can treat at home: an umbilicus that is red or draining pus, skin pustules, or
thrush. These local infections are treated with gentian violet.
As with older children, the success of home treatment depends on how well the
mother or caretaker knows how to give the treatment, understands its
importance, and knows when to return to a health care provider.
Counselling the mother or caretaker of a sick young infant includes the following
essential elements:
309
A. IMMEDIATELY
Becomes sicker
Develops a fever
Fast breathing
Difficult breathing
Blood in stool
310
CHAPTER 23
Stephen N. Kinoti
INTRODUCTION
More than 11 million children worldwide die each year, mainly in developing countries
due to common and treatable illnesses. Interventions to reduce child mortality have paid
little attention to the district hospitals and other facilities providing inpatient care, where
the sickest 20% of children are cared for but quality of care is often poor. Led by WHO’s
Department of Child and Adolescent Development (CAH), the initiative has many facets,
including a study that assessed 21 hospitals providing paediatric care in seven less-
developed countries.i The study (hereafter “Nolan study”) found that 12–34% of sick
children under five who visit health facilities need hospital care. The hospitals exist,
albeit for many children, perhaps half, these hospitals are too far from home.
Nevertheless, if extant paediatric hospitals and paediatric departments of secondary
and tertiary service hospitals were performing optimally, they could save many
children—or spare them immeasurable suffering. The Nolan study found that 14 of the
21 hospitals lacked an adequate system for triage (both assessment and quick
treatment) and that most emergency treatment areas were poorly organized and lacked
necessary supplies. In addition, poor case management (assessment, treatment, and
monitoring) occurred in 76% of hospitalized children. Last, staff had inadequate
knowledge for managing childhood illnesses. The study interpreted these findings as
indicating that “strengthening care for sick children referred to hospital should focus on
achievable objectives with the greatest potential benefit for health outcome. Possible
targets for improvement include initial triage, emergency care, assessment, inpatient
treatment, and monitoring. Priority targets for individual hospitals may be determined by
assessing each hospital.”
“One of many tragic events: In 2004, three other paediatricians, seven medical
officers, 10 nurses and I entered a developing country paediatric ward just as a
gasping 5-year-old was being admitted. We had come to prepare for practical
training in Emergency Triage, Assessment and Treatment (ETAT), which was not
yet established in this hospital. We could not save the child: There was no
oxygen; no emergency tray nor emergency drugs; the medicine cabinet was
locked and the key was not immediately available; no airways, no ambu-bag nor
endotracheal tubes, essentially no resuscitation equipment or medicines were
available. The child was bleeding from cracked lips. He died right there in front of
all of us, and there was nothing we could do. We needed more than skilled staff.
We needed equipment, drugs and other supplies. When you have an experience
like that, it really drives home the fact that skilled human resources are not all
that is needed. To have a hospital that is not basically equipped and has no
emergency response system in place is not just a tragedy for the patients
311
involved, it’s a waste of the investment made in creating and staffing the
hospital,” personal communication, Stephen Kinotiii
LEARNING OBJECTIVES
At the end of this chapter the student will be able to:
Define quality of care;
Explain the factors which determine and influence quality of care
Understand some of the approaches that can be applied to improve quality of services
for seriously ill children
Describe the role of team work in improving quality of services
Describe the scientific basis of modern improvement methods
Identify ways in which he or she could contribute to the quality improvement process
Understand the principle of change and measurement of change as key elements of
modern improvement theory and practice
LEARNING ACTIVITIES
Participate in the adaptation to a national or institutional situation, standards of care for
seriously ill children from internationally accepted standards.
Being part of ensuring the standards of care are available at the care facilities, are well
understood, and available in simplified forms that they can service as job aids when
needed to save lives
Participate in setting up response systems, patient flow processes and procedures that
increase system efficiencies and eliminate redundancies
Participate as a membership of multidisciplinary quality improvement teams
Actively participate in planning, doing, testing and acting (PDSA) on changes that are
found to work and help institutionalize them into routine procedures of work.
Regularly participate in sharing best practices with other teams in other facilities so that
ultimately, the institution, the health system and the country is transformed into a
community of best practice.
In recent years the concept of quality has been expanded to include specific aims for
improvement. For example, the Institute of Medicine's (2001viii) landmark report,
Crossing the Quality Chasm, explains how process changes can improve care,
processes that ensure:
Patient safety. Are the risks of injury minimal for patients in the health system?
Effectiveness. Is the care provided scientifically sound and neither underused nor
overused?
Patient centeredness. Is patient care being provided in a way that is respectful and
responsive to a patient's preferences, needs, and values? Are patient values guiding
clinical decisions?
Timeliness. Are delays and waiting times minimized?
Efficiency. Is waste of equipment, supplies, ideas, and energy minimized?
Equity. Is care consistent across gender, ethnic, geographic, and socioeconomic lines?
The Institute of Medicine in 2001further emphasized the essence of performance
improvement as a function changes in processes.
Performance is a characteristic of a process / system.
In order to improve, the system must be changed in ways that yield better results.
Various inputs in a system yield improvement only to the extent that they can effect
change in that system.
Changes should not only address the individual parts of a system - inputs, processes,
and outcomes, but also the links between them.
A wide range of research activities to test quality assurance methods and approaches,
including studies on training and supervision strategies for the Integrated Management
of Childhood Illness (IMCI), measurement of client satisfaction, and performance
assessment techniques have been undertaken mostly in the 1990s providing increasing
evidence that quality can be improved rapidly. However, to improve clinical practice and
thus quality of care, quality must be defined and measured, and appropriate steps taken
(Silimperi et al 2002ix). This chapter highlights approaches to improving clinical practice
and quality of care for seriously ill children that take place over months instead of years
demonstrating that better quality can improve health much more rapidly than can other
drivers of health, such as economic growth, educational advancement, or new
technology.
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Figure 1: The Framework for Clinical
Quality Improvement
Content of Care
Evidence-
Evidence -based Traditional
•Standards = Quality Improvement
•Protocols
•Guidelines
Process of Care
Continuous
Quality Improvement
Methodology = Quality Improvement
WHO commissioned a study of small hospitals in 1997 that would become known as the
seven-country study (Bangladesh, DR, Ethiopia, Indonesia, Philippines, Tanzania, and
Uganda) (WHO CHD 1998x). The results were published in The Lancet January 2001
(Nolan et al. 2001xi). Results suggested that interventions in referral facilities that are
likely to improve care are clinical training and improvements in organization, such as
patient flow, triage and improving the ability of the health system to provide a regular
supply of drugs and other treatment materials is also needed” WHO CHD 1998. Going
on alongside these efforts was the development of guidelines for Referral Care
published in 2000, “ Management of the Child with a Serious Infection or Severe
Malnutrition: Guidelines for Care at the First-Referral Level in Developing Countries,
also known as the referral care manual or RCMxii. The CHD of WHO noted that the
guideline would also provide the technical foundation for improving quality of care in
referral facilities (WHO CHD 1998). This took care of the content of care in the
framework for quality improvement an essential component but not sufficient to
intervention for higher level of care. This content has been disseminated widely and
used in the 11 days IMCI training, the reduced 6day course and even put into interactive
computer based training formats. It has become clear that the process of care needs to
be improved as well.
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the PDSA cycle of testing changes and if they prove effective, acting to institutionalize
them into routine practice. The following is a model for improvement:
An example of the use of the model for improvement and the PDSA cycles to reduce
waiting time for laboratory results: Gives current practice and changes that were tested
to lead to an improvement.
315
Waiting time reduced to 1 hour; start of Patients treatment much faster and results
based
Observations over a few days covering weekends still good
This is a good improvement
Decision made by Hospital Director to make OPD lab permanent
Spread of an innovation: This innovation was shared during the next learning session
involving service providers from six other hospitals. They thought it was a good idea and
adopted it. Through this process, the innovation was scaled up to many other hospitals.
Examples of such changes may lead to redesign of systems such as introducing triage
systems where they do not exist to better sort out patients that require more urgent care
than those who do not, flow charting to reduce waiting times, using report and request
systems to reduce stock outs of essential drugs and commodities and task shifting to
trained lower level cadres of service providers to increase access to care especially in
the era of HIV/AIDS which is overwhelming health systems, linking PMTCT to child
Health clinics and care and treatment centers to reduce loss to follow up of infants born
to HIV positive mothers. Another of redesign is presented by Molyneux and Malengaxiv
1998, in which they state,
“The introduction of forms called critical care pathways into the pediatric unit of a
hospital in Malawi has strengthened team work, helped to increase the efficiency with
which resources are employed. They serve the dual function of indicating good
management and providing an opportunity to note actions and potential progress.”
316
If the facility which could a hospital or health center is found short of the required level
arrangements are made to support, strengthen the facility to improvement its capacity in
each area of deficiency using quality improvement approaches such as training ,
coaching, testing improvement changes, measuring improvements and reassessments.
Chart Abstraction
Chart abstraction, or review of the medical record, has long been used to measure
technical quality. Such familiar quality evaluations as clinical audits, physician report
cards, and profiles are based on chart abstraction. The core strength of the medical
record is that it is ubiquitous and can generally be obtained after each encounter. Chart
reviews, however, suffer from problems of legibility when notes are handwritten. Often
they are generated for reasons other than recording the actual events of the clinical visit
317
(legal protection or obtaining payments, for example) and thus lack crucial clinical
details. One prospective study showed that charts identified only 70 percent of items
performed during the clinical encounter (Luck and others 2000xvii). In a related analysis,
6.4 percent of the items recorded in the chart were false and had never really occurred.
Nonetheless Yawn and Wollanxviii recommended interrater reliability of completing the
medical records and conclude that it can provide important information to investigators
and to the consumer for assessing the reliability of the data and therefore the validity of
the study results and conclusions.
Where resources and infrastructure are sufficient, the electronic medical record (EMR)
is becoming a priority for health systems worldwide. EMR technology promotes
uniformity, legibility, and communication, which can lead to guideline use and reduce
prescription errors. It also holds the promise of managing populations rather than
individuals by aggregating patients into groups. However, the EMR has not always lived
up to its potential. In many countries, some impressive successes have occurred—as
have spectacular failures, costing billions of dollars (McConnell 2004xix). The great
heterogeneity in record-keeping practices, problems with medical records (both paper
and electronic), and costs of trained medical abstractors have led to a search for other
reliable ways to measure quality.
Administrative Data
Administrative data, collected for purposes of managing the delivery of care, are
available in all but the poorest settings. A data collection system, once established, is
ubiquitous and can provide information on charges and many cost inputs. Administrative
data, however, lack sufficient clinical detail to be useful in evaluating process. In a 2003
study, an incorrect diagnosis was recorded in the data 30 percent of the time (although
the diagnosis was made correctly). Overall, these data reflected the actual clinical
diagnosis only 57 percent of the time (Peabody, Luck, Jain, and others 2004xxi). As
information systems advance, accuracy problems may be mitigated, although the lack
of adequate clinical detail will continue to limit the use of administrative data.
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Standardized Patients
Standardized patients can be a gold standard for process measurement (Luck and
Peabody 2002xxii). Trained to simulate illness, standardized patients present themselves
unannounced into a clinical setting to providers who have previously given their consent
to participate in the study. At the conclusion of the visit, the standardized patient reports
on the technical and interpersonal elements of process. Standardized patients are
reliable over a range of conditions and provide valid measurements that accurately
capture variation in clinical practice among providers over time. However, they are
expensive and useful only for adult conditions and only those conditions that can be
simulated. Thus, they are not practical for routinely evaluating quality.
Growing evidence suggests that the Improvement Collaborative approach has been
shown to increase compliance with standards of care for seriously ill childrenxxiv and to
lead to better outcomes in a number of countries including Malawi, Nicaragua, Niger
and Eritrea in Africa, and Nicaragua in Latin America. Partners in the implementation of
these collaboratives included UNICEF, WHO, Care International, Pan American
Organization and Ministries of Health in the participating countries.
Thus, improvement collaboratives seek to adapt and spread existing knowledge (e.g.,
best practices, evidence-based guidelines) to multiple settings. An improvement
collaborative is made up of 20-40 teams from different organizations or geographic
regions that are all focused on making rapid incremental improvements in a single
technical area and committed to working and learning together intensively for 12 to 18
months. The collaborative engages the teams in working out the operational details in
implementing known best practices in their respective settings. A collaborative can
achieve dramatic improvements in the quality and outcomes of care in a short period of
time by monthly tracking of the pace of improvements and active sharing of strategies
for improvement of services between participating teams. A collaborative is often
followed by a second phase, often known as an expansion collaborative, that provides a
framework for spreading the improvements from the initial or demonstration site to the
rest of the parent health system.
Collaboratives seek to create a culture among participants where everyone learns and
everyone teaches, with friendly competition and urgency to action. Health systems in
developing countries are often viewed as static. Known deficiencies in quality of care,
such as missed opportunities for immunization, persist with no response. Ineffective
processes, such as the referral of the sickest patients, are widely recognized as
deficient, but typically providers do not feel a sense of urgency or a mandate to improve
them. In a collaborative, participants are motivated to participate by the attraction of
being part of a focused, national or international effort; by the desire to apply the latest
scientific or medical knowledge; and by the sense of competing with other teams to
show the greatest improvement. The facilities that join a collaborative usually do so
voluntarily, out of interest in improving an element of care. If there is an administrative
mandate to participate, the senior managers are responsible for making the work of the
collaborative attractive for the teams.
While each PHI Collaborative addressed emergency triage assessment and treatment
and adaptation of WHO referral care guidelines, additional activities addressed specific
problems:
321
• Nicaragua included an emphasis on essential newborn care, neonatal resuscitation,
and prevention of mother-to-child transmission of HIV.
• Niger addressed nutritional recuperation of severely malnourished children in 15 sites.
• Tanzania emphasized improving pediatric AIDS care.
At the start of each collaborative, teams self-assessed their care and then began
introducing site-specific improvements.
Teams met 4-6 times over three years to acquire new knowledge and skills and share
experiences in implementing changes. They also received periodic coaching visits by
local experts. High-performing teams provided peer coaching to slower ones. Teamwork
and coaching help institutionalize the process, create local ownership, and facilitate
faster spread of improvements.
Illustrative Results
Illustrative results
The illustrative results of aggregated data from Tanzania, Niger and Nicaragua are
presented below in the form of time series charts two showing improvements in
compliance with standards of care and one showing improvements in outcomes of care
over the life of the collaboratives in months for demonstration sites and for new spread
sites. Figure1 shows the percentage of children who were triaged upon entry to the
hospital in Niger and Tanzania.
Figure 1: Percentage of Children Who Were Triaged upon Entry to the Hospital in
Niger and Tanzania (2003-2007)
323
Figure 2 shows that in both Niger and Nicaragua the trend is an improvement of
children presenting with emergency conditions who were treated according to norms.
Figure 2: Correct Treatment/Case Management of Children Seen in the Emergency
Room in Niger and Nicaragua (2003-2007)
In all three countries, the trends are that there was improved care for severe pneumonia
in Nicaragua, increased proportion of children treated correctly for Pneumonia in
Tanzania and proportion of children treated for pneumonia according the standard
324
norms in demonstration and spread sites. Figure 4 shows reduction in case fatality
among malaria, Pneumonia and HIV/AIDS cases in Tanzania
Dise ase specific Ca se Fa ta lity Rate s in 5 de mostra tion site s in children with HIV,Ma ra lia a nd Pne umonia
45%
40%
35%
Case Fatality Rate (%)
30%
25%
20%
15%
10%
5%
0%
F J J J
M A M J J A S O N D F M A M J J A S O N D F M A M J J A S O N D F
05 06 07 08
Malar ia.Demo 12 12 10 8% 6% 7% 6% 6% 7% 10 12 9% 9% 12 13 6% 7% 4% 4% 6% 5% 5% 9% 6% 8% 8% 6% 6% 4% 4% 4% 5% 5% 8% 7% 5% 3%
Pneumonia. Demo 20 23 14 16 17 17 10 12 16 9% 11 12 17 13 16 11 9% 12 14 14 15 15 17 15 14 12 9% 8% 7% 9% 8% 10 11 15 18 10 12
HIV. Demo 28 42 10 14 20 41 30 30 30 19 24 29 19 16 17 21 13 18 17 21 4% 11 19 23 22 19 21 8% 14 10 12 21 8% 16 6% 18 26
Months
Conclusions
A number of quality improvement options have been tried in many countries both in the
developed and developing countries with various degrees of success. Over time
however, it has become clear that these different options have a role to play in bringing
about improvement in systems of care and outcomes of care. The improvement
collaboratives have been used extensively in developed countries and are taking root in
developing countries and have contributed to improving the quality of pediatric services
in first referral hospitals.
Significant improvements in patient flow and triage have been set up, special areas for
very sick children have created such as emergency rooms and spaces equipped with
emergency trays and drugs, oxygen concentrators and means of resuscitation provided.
Compliance with standards of care has improved by a range of 30%-50%; case fatality
came down by about 15-30% among the most difficult situations and by about 50% in
the more affluent countries all in a short period of time and with little financial
investment. Staff morale has significantly improved in all the PHI countries.
Other system improvements include the application of standard care and treatment
guidelines, building capacity of providers in continuous quality improvement, and
monitoring changes in care quality over time. Improvements achieved in demonstration
sites have been spread to new sites, where improved outcomes have been achieved
more rapidly than in the original sites. The collaborative approach by combining a
number of other improvement methods is not the only way but an effective way to
introduce standards of care, apply them, and rapidly increase compliance with these
standards leading to improved outcomes of care.
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CHAPTER 24
1.0 INTRODUCTION
Equal access to health care is accepted as a right and this was endorsed by member
states of WHO in the Alma Ata Declaration (WHO/UNICEF 1978) with commitment to
the target of health for all by the year 2000. Since then, many achievements have been
made in terms of health infrastructure, health service delivery, and human resource
development in the health sector. Due to inadequate allocation of financial resources by
many governments to the social sector, particularly to the health sector, alternative
methods of financing health Services had to be developed. Other broad areas included
within health reforms are: human resource development, quality assurance,
decentralization, integration of services, health information management and research.
At this time when most countries in Sub-Saharan Africa (SSA) are instituting health
reforms, all health workers particularly medical doctors need to be knowledgeable in all
aspects of health reforms formulation and implementation.
2.0 OBJECTIVES
At the end of this chapter the student will be able to:
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Describe human resources necessary to provide quality child health care
services at the health center level;
Estimate the cost of providing such a service;
Describe the integrated management of common childhood and maternal
illnesses including family planning;
Plan the evaluation and monitoring of services provided to children at a health
facility;
Describe health information needs at various levels of the health care system;
Identify research needs at various levels of health care with respect to child
health.
Describe the available clinical protocols and guidelines at the health facility for
specific health service management.
UNICEF advocates that all governments should allocate at least 20% of their national
budgets to the social sector, especially to Health and Education (the 20/20 principle).
This can be easily done by reducing on military spending.
In many countries in the region, private medical services within the public medical
facilities are used to help generate supplementary funds for the public health facility.
Community financing schemes such as the Bamako Initiative schemes are already
being implemented successfully in several countries with full community participation.
The communities themselves have established criteria on who should be exempted
from paying fees, such as the very young and elderly. Revenues from such payments
can then be used to promote health services in the area. Community financing can be in
form of: giving cash, labor, or other provisions from which no single individual benefits,
but the whole society. Tanzania introduced community health financing several years
back. The programme has been well accepted in the three districts of Tabora regions.
The programme is now being scaled up in the country.
8.0 Decentralization
Though many countries have embarked on decentralization, effective decentralization
including delegation of authority to hire and fire, and to manage financial resources is
still lacking. A number of factors that have rendered the decentralized health system
less effective are:
The central level still retained most of the authority, some of which would be
necessary to facilitate implementation at the district level. Vertical programs are
planned at the central level with very little participation of the implementers.
The concept of decentralization is not well understood and there was a tendency
of by-passing the relevant authorities in the handling of health management
issues and also in decision-making involving finances.
Lack of clear decentralization Policy that would empower district authorities to
attain full administrative and managerial powers.
Inadequate support to the district health management teams to enable them to
fulfill their supervisory roles and ensure that the quality of health services is
maintained by providing guidelines and manuals.
Lack of comprehensive health sector plans that would be used by central
ministries to implement health activities at all levels and coordinate donor input.
Inadequate health staffing and equipment for delivery of a minimum level of
acceptable health care.
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10.0 Health Information System
This aspect of reform must include development and coordination of health information
systems that are useful for:
Advocacy and policy development,
documenting the burden and nature of illnesses,
Monitoring quality and performance of health services.
Estimating the cost of health service,
Monitoring trends and changes on the overall health sector and
Regular synthesis of health information useful in planning.
11.0 Research
Most of the research on health including operational and bio-medical have not
depended on the demand of the national health system. Research in the reforms should
include essential national health research at all levels and the objectives should be:
Operational research should especially address the aspects that deal with strategies,
approaches, access and utilization of services. They should also address technologies,
financial systems, quality assurance, case studies of functioning systems or strategies
and disease control.
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REFERENCES:
331
CHAPTER 25
INTRODUCTION
Statistics is the science of collecting, organizing and interpreting numerical facts which
we refer to as data. Data are not just numbers, they are numbers within a context. The
statistical approach in health care pertains to defining and interpreting health
phenomena using numbers. This chapter presents some of the basic statistical
techniques which can be used to analyze and present statistics pertinent to primary
health care.
The purpose of the chapter stimulate students and other health workers to study more
statistical theory and methods in order to be equipped to collect reliable data and
accurately analyze such data.
OBJECTIVES
At the end of the chapter students should be able to:
Explain the role of statistics in Health Care
Discuss common and possible data sources on Health Care
Understand basic statistical parameters relevant to health related data including:
Rates and proportions
Measures of central tendency
Measures of dispersion
Tabular and graphic presentation of data
1. Censuses
2. Vital registers
Registration of all deaths and births is required by law in most countries. A death
certificate is required for claiming insurance benefits of other administrative rights of the
deceased’s property. For countries which have complete or near complete vital
registration systems, vital statistics, including births and deaths can be generated on a
continuous basis. Unfortunately for most African countries the systems for registration
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of births and deaths are not comprehensive. In general registration is better in the
urban settings compared to the rural areas.
The national demographic and health survey obtains detailed information on fertility
levels, marriage, and sexual activity, breastfeeding practices, nutritional status of
women and children, childhood and maternal mortality, maternal and child health,
vaccination coverage, awareness and use of family planning methods, behaviour
related to HIV/AIDS. Some countries also include information on malaria and use of
mosquito nets, domestic violence and HIV testing of adults.
Hospital, clinic records and other primary health care records: health statistics can also
be generated as byproducts of hospital, clinic and other administration systems. In
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general information from the hospital records may not be representative of what
happens in the community. For instance during an outbreak of measles the children
who get admitted and die in the hospital may only represent the sickest subset.
1. Count: The absolute number of an event (e.g. infant’s deaths) occurring in a specified
area in a specified time period. For example, there were, 24,560 infant deaths recorded
in South Africa in 1996.
Absolute numbers are important for planning. In a specific country the number of
malaria infections may be used to plan the quantity of antimalarials required for a given
duration.
Consider the proportion of patients infected with HIV in two countries (hypothetical).
Country A has a total population of 2,000,000 people of whom 200,000 are HIV
infected.
200,000/2,000,000 = 10%
Country B has a population of 100,000,000 and has 1 million HIV infected people.
The proportion of HIV infected people in country B is:
1,000,000/100,000,000 = 1%.
Thus even though the absolute number of cases is higher in country B (1 million vs.
200,000), the proportion is higher in country A (10% vs. 1%).
4. Rate: A rate, measures a frequency of public health events among, say, children in
a specified time period. For example the infant mortality rate for Egypt, in 1999, was
29.4. This rate is the annual number of deaths of infants under one year of age per,
1,000 live births in the same year.
5. Incidence rate: Is the count of new (incident) cases divided by the amount of at-risk
experience from which the cases arose. The denominator is measured in units of
person-time.
Note: person-time is defined as the amount of follow-up time each individual contributes
e.g. 50 people followed for 1 year contribute the same number of person years as
100people followed for 6 months (i.e. 50 years)
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6. Prevalence rates: Count of prevalent cases of a disease is the number of persons in
the population who are in the diseased state at a specified time. The proportion is
obtained by dividing the count of prevalent cases by the population size at the time.
Descriptive Statistics
Descriptive statistics are frequently used and can be used in different aspects of primary
health care. For instance, they are used when we want to describe how the data at
hand looks like and its common features. Descriptive statistics summarize data. The
summarized data, in most cases, facilitate easy and quick interpretation of the detailed
set of data. In health care, descriptive statistics can be and are used to manage,
monitor and evaluate health services and the persons working in such services
Descriptive statistics are, in general, categorized into two types: The first being
measures of central tendency, namely, the mean, median and mode. The second
category is measures of dispersion/variability, among them the range; inter quartile
range; variance and standard deviation.
There are 2 types of variable namely categorical variable and continuous variables.
Categorical variables include those which naturally occur in distinct groups e.g. sex
whereby one can only be either a male or female. Continuous data on the other hand
does not fit into natural groups and changes occur in gradual increments. Examples of
continuous variable are height and age.
It should, however, be pointed out that there a number ways of defining the measures
of central tendency. In this section we shall consider the following measures of central
tendency:
Mean
Median
Mode
Mean The arithmetic mean, which is the most commonly used measure of central
tendency, is simply the total of a set of values of a variable divided by the number of
observations. Thus, it is calculated by summing all the values in a set of data and then
dividing the total by the number of items involved. The data may come from the whole
population of interest, or a sample for example, recorded height in centimeters of a
sample of children (see table 1).
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The formula for the population mean is
x1 x2 x3 x N
N (1)
Where x1 up to x N are the observations for the whole population N in our example
above of sick children in a particular hospital ward. The Greek letter mu represents
the mean of the population.
x
i 1
i
= N (2)
N
x i
i 1 is the summation of all xi values in the population from x1 to? x N
x1 x 2 x3 x n
x n (3)
x i
is the summation of all xi values in the sample from x1 to? xn
i 1
Serial Height in
number of centimeters xi
2
child x i
1 65 4,225
2 75 5,625
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3 85 7,225
4 95 9,025
5 100 10,000
6 105 11,025
7 115 13,225
8 120 14,400
9 125 15,625
10 125 15,625
11 127 16,129
12 135 18,135
13 145 21,025
14 155 24,025
15 170 28,900
16 170 28,900
17 170 28,900
18 170 28,900
19 170 28,900
20 170 28,900
x i
x = n
65 75 85 95 100 170
= 20
2,476
= 20 = 123.35 123
Median: The median, which is another common measure of central tendency, is the
middle value, thus the physical centre, in an ordered sequence of data of a distribution
or data set. If the order set of number is odd, half of the observations will be smaller and
half will be larger than the middle value. The observations should be ranked from
lowest to highest value before determining the median. The median is less affected by
outliers in a set of data than the mean. Instead of using all the values to calculate the
measure of central tendency, it uses only the value in the middle of the distribution. It is,
therefore, often preferred as a measure of central tendency for skewed distributions.
To calculate the median, therefore, first the raw data should be put in an ordered array,
say in ascending order. In general the positioning point formula is:
n 1
2 (4)
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where n is the number of observations?
(a) If the number of observations is odd, the median is represented by the numerical
n 1
value corresponding to the positioning point, which is the 2 ordered observation.
(b) If the number of observations is even, then the positioning point lies between the two
middle values. In this case the median is the arithmetic average of the numerical values
corresponding to the two middle observations. We shall illustrate the above two
situations in the examples that follow.
Example
125 127
Median = 2 = 126
If the number of children we only 19 the median height should have been 25 by applying
formula (4) above in locating the median position.
Mode: The mode is the value in a set of data (distribution) which occurs most frequently.
It is easily obtained from an ordered array. The mode, unlike the mean is not affected
by presence of outliers a set of data.
It should however, be noted that the mode is used mostly for descriptive purposes
because it is, in practice, more variable from sample to sample compared to other
measures of central tendency.
From table 1 it is clear the most frequent value is 170, thus six observations in the
distribution.
The mean is the most commonly used measure of central tendency. All values in a
selected distribution are used in its calculation, in this way it is the most sensitive. As it
arithmetically based it can be used in other calculation as illustrated below under the
measurement of variation. As earlier stated, however, it is easily distorted by extreme
values. In addition, the mean can only be used on data of interval or ratio level of
measurement.
The median does not take into account the values of cases, therefore is not affected by
extreme values. It can be derived from ordinal, thus ranked data.
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The mode is most useful categorical data, although it can be used on all levels of
measurement.
Measures of Dispersion
A single summary measure such as the mean is, under normal circumstances, sufficient
to describe or define a distribution, because it does not reflect the second important
characteristic of a distribution, namely, its variation or dispersion. In order, therefore, to
enhance our understanding of the pattern of the data there is also a need to measure its
dispersion. Why do we need to measure and understand dispersion of a distribution?
It gives additional information that enables one to assess the reliability of the measure
of central tendency. For example, if data are widely dispersed, the measure of central
tendency is less representative of the data as a whole than it would be if the data were
more closely clustered around the mean, for instance.
The measure of dispersion is the one of the first steps to take in an attempt, to resolve
peculiar problems associated with widely dispersed data.
It is important to note that in the health care field it is important to know the variability in
children’s health.
1. Range: To calculate the range you subtract the smallest value, in a data set, from
the largest value. As example once again refer to table 1. The smallest and largest
value in the distribution is 65 and 170, respectively.
2 Inter-quartile range: In order to deal with outliers in a distribution the use of an inter-
quartile range ( IQR ) is advisable. A quartile is derived by partitioning a data set into
quarters. The data are placed in an ascending order and then divided into four quarters.
The numbers at the upper boundaries of these quarters are called quartiles. Thus the
quartiles are the highest values in each of the four parts. The IQR measures,
approximately, how far from the median one has to go on either side before one
includes 50 per cent of the data set. The IQR is, therefore, the range for the middle fifty
per cent of the data.
The IQR is calculated by locating the upper value of the 1st quartile, and subtracting it
from the upper value of the 3rd quartile. Thus
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IQR = Q3 Q1 (5)
= 170 – 100 = 70
It will be observed that the dispersion is somewhat reduced compared to the value of
the range. This is because its calculation, to the extent possible does not include
outliers such as 65.
One obvious shortcoming of the range and the IQR is that while they give an
indication about the spread of values of observations, they do not take into
consideration the concept of the level of deviation from the central tendency ( such as
the mean).
3. Variance: The variance is an average of squared deviations from the mean. As can
be seen from the formulas below, The sum of squared deviations/distances between the
mean and each item divided by the total number of elements in the population. In the
case of population variance, by squaring each deviation, we make every number
positive.
2
Population and sample variances: The Square of the Greek letter sigma ( ) usually
represents the population variance, while the sample variance is commonly represented
2
by s . The formulas for variances are as follows:
2 2
x i x i
2
2
Population: = N = N (6)
x 2
2 2
i x x
nx i
Sample: s2 = n 1 = n 1 n 1 (7)
Where:
xi is a value of an element?
is the population mean
x is the sample mean?
N is the total number of observations in the population?
n is the sample size
N-1 is the number of observations in the sample minus 1
2 is the population variance
s 2 is the sample variance
In the calculations we use the data in table 1 which we assume to be sample data. In
our calculation we use the simplified formulation, thus:
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2 2
x
nx
i
2
s = n 1 n 1
358,404 304,304.40
= 19 19
= 18,864.37- 16,016.02
= 2,848. 35
= 2,848
4. Standard deviations (SD) The standard deviation of the population and sample
variances is the square root of their variances.
x 2 2
i x i
2
i) Population N = N (8)
x 2 2 2
i x x
nx i
SD s 2,848.35
= 53.37
53
The standard deviation is the most commonly used measure of dispersion in describing
data. It is the measure of the variation in the data that assesses how much each value
deviates from the mean.
Most naturally occurring distributions are normal. In such distributions, the mean is very
close (or equal) to the median. However some distributions are skewed (either right
skewed in which case the mean is far greater than the median, or left skewed in which
case the mean is significantly less than the mean. The median is relatively unaffected
by extremes figures (in statistics the mean is considered to be robust).
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The best representation of normal data uses the mean and standard deviations while
skewed data is best represented using the median and inter quartile range.
When data are collected, there is need to present them in an orderly manner for them to
be understood, especially, when you have a large array of data. Data can grouped into
classes or frequency distributions; presented in a tabular form or charts and as
discussed above calculated and presented as summary statistics. Tables and graphs
summarize and present data in a way that is easy to understand and assimilate.
Displaying data is usually an important part of analyzing the data. According to Scott
and Mazhindu, (2005) “it allows you to establish how data are distributed, to see
unusual cases and generally get a feel for the data.” Tables present information in a text
form while graphs help display patterns although some details are lost.
We briefly discuss and present a table; line graph; bar chart; multiple bar chart and pie
charts derived from the small data set given in table 2.
It should be pointed out that many more graphs and charts are used by statisticians and
other data users to display data.
1. Tables: The purpose of tables is to summarize and thereby facilitate the comparison
of data.
Listed below are the general features of which a good table should have:
A title which is a brief explanation of the contents of the table including the units of
measurement;
A column title or caption showing the classification with respect to columns
A row title or stub to showing classification with respect to rows.
A source note at the bottom of the table indicating the source of data.
Sex
Age
Male Female
10-11months 11 7
12-24
1 2
months
2-5yrs 2 4
6-10 yrs 2 1
Total 16 14
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Questions:
What proportion of the all children are males?
What is proportion of female sin the age group 6-10 years?
From this table do you think male infants are more likely to be battered?
2. Line graph: To draw a line graph we must have values which are pertinent to the y -
axis (vertical axis) and x - axis (horizontal axis). The position of any point on the graph
is located by the y and x coordinates. With respect to figure 1 examining the female
line graph the number of battered children in the age range 10-11 months is 7, as we
move along the x -axis the number reduces to 2 battered children in the age range 12-
24 months. Then we move upward on the scale until the number 4 for those battered
aged 2-5 years and then declines to 1 for those aged 6-10 years. A straight line is then
drawn through the located points.
Figure 1. Number of battered children at Kenyatta Hospital by age and sex (1989)
12
10
8
Number
Male
6
Female
0
10-11mons 12-24 mons 2-5yrs 6-10 yrs
Age
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Bar Chart: In a simple bar chart the bars are of equal thickness but the length is varied
in proportion to the values represented. This chart is given in figure 2. below.
12
10
8
Number
6 Series1
0
10-11mons 12-24 mons 2-5yrs 6-10 yrs
age
4. Multiple Bar Charts In figure 3 we see a graph where two sets of data have been
graphed using the same values (age ranges) in the horizontal axis. This graph, for
example, facilitates easy graphic comparison of number of battered boy and girls by age
group.
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Figure 3. Battered children at kenyatta Hospital by sex and age (1989)
12
10
8
Number
Sex Male
6
Sex Female
0
10-11mons 12-24 mons 2-5yrs 6-10 yrs
Age of children
5. Pie chart:
A pie chart displays a count of observations in a nominal group as a proportion (per
cent age) of the total number of counts. The total data is represented as a circle which
is divided into segments whose sizes represent the frequency of each group. For
example figures 4 and 5 shows the proportions of battered boys and girls, respectively,
under different age groups. Pie charts are ideal for simple data. If you include many
subgroups or categories it may be difficult to read.
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Figure 4: Male battered children at kenyatta Hospital by age
6-10 yrs
13%
2-5yrs
13%
10-11mons
12-24 mons
2-5yrs
12-24 mons 6-10 yrs
6%
10-11mons
68%
6-10 yrs
7%
2-5yrs
29%
10-11mons
10-11mons 12-24 mons
50% 2-5yrs
6-10 yrs
12-24 mons
14%
Spend some time analyzing the graphs and charts and come up with an objective
story!
346
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1SP.
Kenya demographic and health Survey 2003. Central bureau of Statistics, Nairobi
Kenya.
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J. Peabody, J. Luck, S. Jain, D. Bertenthal and P. Glassman. 2004. Assessing the
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Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare
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