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DEDICATION
Remembering Prof. Donald A. Hillman
Professor Donald Hillman died on 4th July 2006. He was a world renowned
paediatrician, a champion of International Health, and a strong advocate for
improving child health worldwide, particularly in developing countries. This third
edition of “The Primary Health Care manual for medical students and other health
workers” is dedicated to Don Hillman. His work will forever live on through the
generations of undergraduate and postgraduate medical students all over the world
whom he mentored and influenced in their careers, together with his wife Liz Hillman.
Dr. Donald Hillman graduated in Medicine at McGill University in Montreal, Canada
in 1949. He received his postgraduate education at the Montreal Children’s Hospital,
the Hospital for Sick Children in Toronto and at the Massachusetts General Hospital
in Boston. He completed his PhD. in Investigative Medicine at McGill University in
1961. He subsequently became a Professor of Paediatrics and Associate Dean of
Postgraduate studies at McGill University, and a Professor in Paediatrics at Memorial
University in Newfoundland.
From 1976 to 1989 Don Hillman and his wife Liz Hillman joined the then new Faculty
of Medicine at Memorial University of Newfoundland as Professors of Paediatrics.
Don Hillman became Physician-in-Chief and Liz Hillman was Director of Ambulatory
Education at the Janeway Child Health Centre. In 1989 The Hillmans joined
McMaster University in Hamilton in the field of international health. They later moved
on to the University of Ottawa in the same field, now generally referred to as Global
Health.
Internationally the Hillmans have also had a long and illustrious career having
worked in more than 15 countries as consultants or visiting Professors. This includes
Kenya, Uganda, Tanzania, Zambia, South Africa, China, Kuwait, Singapore, Laos,
Malaysia, Bhutan, India, Guyana, Philippines and Pakistan. In the early 1970s McGill
University teamed up with the Canadian International Developing Agencies (CIDA) to
support the development of a new medical school at the University of Nairobi in
Kenya. In 1974 Don and Liz Hillman accepted a four year appointment in the
Department of Paediatrics and Child Health at the University of Nairobi. They worked
together with Prof. Nimrod Bwibo and Dr. Alan Ross to strengthen the teaching of
Paediatrics and Child Health at the University of Nairobi. This has now grown to be
one of the largest undergraduate and postgraduate medical teaching programmes in
Africa. Don and Liz Hillman later moved on to Makerere University in Uganda where
they managed another CIDA funded project known as CHAMP (the Child Health and
Maternal Educational Programme). They also served in senior advisory positions
with UNICEF Kampala
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The McGill and Nairobi programmes and the CHAMP programme in Uganda were
later to influence the development of the CIDA funded Primary Health Care East
Africa (PHCEA) project in the late 1980s which was negotiated and championed by
the Hillmans. The PHCEA project focused on improving the teaching of Paediatrics
and Child Health in Kenya, Uganda, Tanzania and Zambia, including the exchange
of students and staff. This project produced a popular teaching manual - The 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.
In recognition of this lifetime commitment and tremendous contribution to Global
Health spanning over thirty-five years, the Hillmans received several awards. This
includes the Ross Award (1989), the prestigious Orders of Canada (1994), the
James H. Graham award (1995) the Lifetime Achievement Award of the Canadian
Society for International Health, recognition by the American Academy of Paediatrics,
and honorary doctor of laws degrees.
As we celebrate the life of Don Hillman, we thank him and his wife Liz for the
tremendous contribution and lifetime commitment to international health, which will
remain an inspiration for many years to come, to all of us including many generations
of medical students and paediatricians all over the world. We dedicate this third
edition of the “Primary Health Care Manual for medical students and other health
workers” to our friend Don Hillman.
May His Soul Rest in Eternal Peace!
Prof. Kopano Mukelabai,
Department of Paediatrics and Child Health, University of Zambia, Lusaka, Zambia
Formerly:
Chairman of the Department of Paediatrics and Child Health at the University of
Zambia
Dean School of Medicine, University of Zambia (1984-1992)
Senior Health Adviser in UNICEF (1992-2009)
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PREFACE TO THE THIRD EDITION
The Third Edition of the Primary Health Care manual has finally been produced.
Lack of funding due to the global economic recession, has partly contributed to the
delay in producing the current manual. We are very grateful to the University of
British Columbia and specifically to Prof. Stuart Macleod and his wife Nancy for their
concerted efforts to raise the critical funds needed to print the manual. We are also
very grateful to Prof. Elizabeth Hillman and the Hillman Foundation for providing
extra funds to print more copies of the manual and for providing funds to distribute
the manual.
The third edition of the PHC manual is dedicated to our friend and colleague
the late Prof. Donald Hillman who died on 4th July 2006.
Don Hillman, together with his wife Liz mooted the whole idea of the PHC East Africa
Project and the subsequent publication of the PHC manual. We have written an
obituary printed in this book to honour the life and work of Prof. Donald Hillman.
The PHC manual is still very frequently used to teach both undergraduate and
postgraduate medical students. This new edition will be distributed free of charge to
seven medical schools in five countries in Eastern and Southern Africa. These are
Zambia, Kenya, Tanzania, Uganda, and Ethiopia. The first two editions of the manual
proved to be extremely popular among medical students and other health workers.
The major preparation of the third edition of the PHC manual took place at a meeting
held at the Silver Springs Hotel in Nairobi in October 2008. It was a wonderful and
productive meeting with representatives of 10 Universities present, including one
representative from UNICEF. Other topics covered during the meeting included;
sharing information on the postgraduate curriculum, exchange of staff and students,
and conduction of joint research.
With five years remaining towards the attainment of the MDGs by 2015, the PHC
manual will make an important contribution in assisting countries to achieve the
health related MDGs. A few new chapters have been added to the manual to make it
more comprehensive. We have also included the April 2008 Ouagadougou
Declaration on PHC in Africa, which was signed by Ministers of Health from all
countries in Africa.
May the spirit of Don Hillman continue to guide the future direction of the PHC
manual and its use by medical students and other health workers!
Finally let me once again thank all my colleagues who participated in the production
of this third edition. Their commitment was total as they showed an incredible
patience and understanding in waiting for the final production of the new manual. I
also wish to thank Ms. Ruth Matano and Ms. Rosemary Mwasya for assisting us in
organizing an extremely successful workshop to revise the third edition of the
manual. Ms. Matano also assisted in preparing the final script of the new manual.
Kopano Mukelabai, 31
st
March 2010.
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PREFACE TO THE FIRST EDITION
This manual is designed to meet the learning needs of medical students and other
health workers, to achieve competence in the understanding and management of
priority problems in Primary Health Care in Zambia, Uganda, Tanzania and Kenya. It
is applicable to other countries especially those in Africa with similar health
problems.
Each chapter of the manual, has objectives related to an important Primary Health
Care topic, and defines the knowledge, skills and attitude required to meet these
objectives. The manual is intended to supplement paediatric texts and other
reference materials, and is a targeted aid to Primary Health Care problem solving
both in tertiary and Primary Health centres, which should both be the major sites for
relevant health learning. Some of the chapters contain case illustrations designed to
facilitate learning by presenting real-life problems relevant to the topic.
The manual contains self evaluation questions and a list of objectives. Other learning
materials supplied by other institutions and organizations like W.H.O., UNICEF, etc.
may be very useful. For the manual to be of continuing value, the students and the
teachers must add relevant details of priority health problems in their region with
particular focus and emphasis on the overall child health programmes. This should
include collaborative emphasis on links between the training programmes and the
country's health care system, both governmental and non-governmental.
In order to adapt to the rapidly changing field of primary health care teaching,
revisions and additions to the problems presented here, must be developed by
teachers and students to reflect changing priorities and approaches.
The editor wishes to thank the Canadian Government for providing the crucial
financial support through CIDA (Canadian International Development Agency) to the
Primary Health Care East Africa Project. Special thanks go to Memorial University of
Newfoundland, which was the Canadian collaborating medical school, and its two
dedicated faculty members Prof. Donald Hillman and Prof. Elizabeth Hillman.
I wish to acknowledge with thanks the strong support of the Universities of Zambia,
Dar-es-Salaam, Nairobi and Makerere, which through their Principals and Deans,
gave the widest latitude to their Chairmen of Departments of Paediatrics and Child
Health and their staff and students, to successfully implement the Primary Health
Care East Africa (PHC/EA) project.
Particular thanks go to the Chairmen of Departments of Paediatrics and Child Health
and the Hillmans, who together mooted the whole idea of PHC/EA. Their
congeniality, and extreme dedication ensured the smooth implementation of the
project's stated objectives.
To Prof. Gabriel Anabwani, the first programme manager of PHC/EA project, who
worked so hard to overcome most of the teething problems encountered, I say
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special thanks, and thanks go to all our departmental Secretaries who bore the brunt
of retyping the illegible manuscripts. Particular thanks go to Mrs. Jane Thairu,
University of Nairobi for typing the draft manuscript on her ACER 910, and to Mrs.
Beatrice Mwanamuchende and Ms. Shirley Kapapa of University of Zambia who
typed the revised final manuscripts.
Finally my gratitude goes to all our students and fellows whose constant quest for
more knowledge was the prime mover for the production of this manual.
The following are thanked for contributing directly or indirectly to the manual:
Prof. Donald Hillman, Memorial University, Newfoundland;
Prof. Elizabeth Hillman, Memorial University, Newfoundland;
Prof. Stuart Macleod, Dean, MacMaster University, Hamilton, Canada;
Prof. Vic Neufeld, McMaster University, Canada;
Prof. N. Bwibo, former Principal, University of Nairobi, College of Health Sciences;
Prof. H. Pamba. former Dean, Faculty of Medicine, University of Nairobi;
Prof. W. Makene - former Dean, Muhimbili Medical Center Dar-es-Salaam;
Prof. G. Mwaluko, former Dean and Director General, Muhimbili Medical Centre,
Dar-es-Salaam;
Prof. J. W. Mugerwa, Dean Faculty of Medicine, Makerere University;
Prof. R. Owor - Former Dean, Faculty of Medicine, Makerere University;
Prof. Julius Meme, former Chairman, Dept. of Paediatrics and Child Health,
University of Nairobi;
Prof, F. Onyango, Chairman, Dept. of Paediatrics and Child Health, University of
Nairobi;
Prof. R. Mbise, former Chairman, Dept. of Paediatrics and Child Health, University of
Dar-es-Salaam;
Dr. E. Mwaikambo, Chairman, Dept. of Paediatrics and Child Health, Muhimbili
Medical Center, Dar-es-Salaam;
Prof. C. Ndugwa, Chairman, Dept. of Paediatrics and Child Health, Makerere
University, Kampala;
Prof. K. Mukelabai, Dean and former Chairman of Department of Paediatrics and
Child Health, University of Zambia, Lusaka;
Dr. Alfred Mutema, Nairobi;
Mr. L. Dierick, Nairobi;
Prof. Peter Kinyanjui, Common Wealth of Learning, University of Vancouver Canada;
UNICEF; All Primary Health Care East Africa Fellows; All Faculty members of
departments of Paediatrics and Child Health at Universities of Zambia ; Dar-es-
Salaam, Makerere and Nairobi. Finally I wish to thank all my colleagues for their
maximum cooperation and patience in implementing the PHC/EA project to the end.
This manual lends credit to your dedicated and excellent efforts.
Prof. Kopano Mukelabai, Dean School of Medicine, University of Zambia, Former
Chairman of the Department of Paediatrics. University of Zambia.
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A MESSAGE FROM DR. HAFDAN MAHLER, FORMER DIRECTOR GENERAL OF THE
WORLD HEALTH ORGANIZATION
Health Care Workers and PHC
World Health will improve only if the people themselves become involved in planning,
implementing and having a say about their own health and health care. But involvement
will not just happen. How serious are we about involving individuals, families and
communities? Are we prepared- mentally and professionally to listen to their concerns, to
learn from them what they feel is important, to share with them appropriate information,
encourage and support them. Are we ready to assist them in choosing from alternative
solutions, in setting their own targets and evaluating their efforts?
In many cases, so far, the answer is no. We can go on and on developing plans: nothing
will happen unless all health workers, all health managers, and key professionals in other
sectors come to realize what is at stake.
First, health workers must understand that the concept of primary health care involves new
roles for them and a new outlook. Not only should we be concerned with disease
prevention and control, we must also be concerned with health promotion and care - and
not least with development in general – and with people. Our health technologies must be
based on what the people themselves want and need. In other words, the worker should
learn first and foremost to act as a facilitator of action by individuals, families and
communities. We must stop trying to fit communities into systems and programs we
devise, without a real and deep feeling for the social aspects of health problems or the
economic constraints-not to speak of the cultural dissonance that is often the backlash of
such programs.
Second, health workers must accept their new roles. They must accept new ideas, must
be taken to try them out, to adapt them, to broaden their scope and innovate in the
partnership approach. Their main concept must be to find ways of helping individuals and
communities become self-reliant. It must be made clear that advocating self-reliance in
health matters in no way means abdicating our responsibilities and passing them on to
someone else. Both lay persons and professionals are essential. They cannot replace
each other, but they must work together.
This brings me to my third point: health workers must have the necessary skills to perform
these new roles effectively and to make efficient use of existing knowledge. This calls for a
training force fully familiar with accumulated experience and keen to provide the kind and
quality of professional preparation needed. It also calls for full backing from health
managers for such training.
All health care workers must meet these requirements. This manual helps define the role
of health workers in Primary Health Care. Your skills and commitment to this role will be of
critical importance to the achievement of Health for All by the year 2000.
Halfdan Mahler, Former Director General, World Health Organization
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TABLE OF CONTENTS
Page No.
i Dedication to Prof. Donald Hillman
iii Preface – 3rd Edition
iv Preface – 1
st
Edition
ix A message from Hafdan Mahler former WHO Director
General
CHAPTERS AND AUTHORS
1 1 PRIMARY HEALTH CARE
Elizabeth Hillman, Kate Wotton,
Kopano Mukelabai
16 2 CARE OF NEW BORN
Rachel Musoke, Mary Shilalukey Ngoma,
Aggrey Wasunna
25 3 INFANT AND YOUNG CHILD FEEDING
(IYCF)
Rachel Musoke, Ruth Nduati, Aggrey
Wasunna
43 4 CHILD NUTRITION
Ruth Nduati, Ahmed Laving, Heena Hooker,
Peter Ngwatu
60 5 EARLY CHILDHOOD DEVELOPMENT
Ruth Nduati
76 6 GROWTH MONITTORING AND
PROMOTION DURING EARLY
CHILDHOOD
Daniel Njai, Rachel Musoke, Ruth Nduati,
Aggrey Wasunna
97 7 CHILDHOOD IMMUNIZATION
Amos Odiit, Esther D. Mwaikambo
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Page No. CHAPTERS AND AUTHORS
105 8 CONTROL OF DIARRHOEAL DISEASES
Israel Kalyesubula
118 9 ACUTE RESPIRATORY INFECTIONS IN
CHILDREN
Elizabeth Maleche-Obimbo,
Ezekiel M Wafula
131 10 ASHMA IN CHILDREN
Chris M. Ndugwa, Somwe Wa Somwe,
Elizabeth Maleche-Obimbo,
Dalton Wamalwa, Dinberu Tefera Muluwork
139 11 TUBERCULOSIS IN CHILDREN
Elizabeth Maleche-Obimbo,
Andrew Ndamira, Catherine Chunda
152 12 MALARIA IN CHILDREN
Amos Odiit, Sarah Kiguli, Samuel Ayaya,
Esther D. Mwaikambo
163 13 HIV INFECTION AND AIDS IN CHILDREN
Gabriel Anabwani, Israel Kalyesubula,
Ruth Nduati, Catherine Chunda,
Elizabeth Maleche-Obimbo
176 14 ANAEMIA AND SICKLE CELL
DISEASE
Catherine Chunda, Chris Ndugwa,
N. Kariuki, Nimrod O. Bwibo
186 15 ADOLESCENT HEALTH, DRUG AND
SUBSTANCE ABUSE
S. Bakeera-Kitaka, Amos Odiit,
Samuel Ayaya, Esther D. Mwaikambo
194 16. ACCIDENTS AND POISONING
FV Murila, Chris M. Ndugwa, Ruth Nduati,
Somwe Wa Somwe, Dalton Wamalwa,
Dinberu Tefera Muluwork
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,
Page No. CHAPTERS AND AUTHORS
211 17 CARDIOVASCULAR DISEASES IN
CHILDHOOD
Christine Yuko-Jowi, Gabriel Anabwani
222 18 COMMON SKIN DISEASES IN CHILDREN
Samuel Ayaya, Amos Odiit,
Esther D. Mwaikambo
233 19 ESSENTIAL DRUGS AND RATIONAL
USE OF ANTIBIOTICS
Chris M Ndugwa, Somwe Wa Somwe,
Elizabeth Maleche-Obimbo,
Dalton Wamalwa, Gabriel Anabwani
Dinberu Tefera Muluwork,
251 20 CHILDREN IN ESPECIALLY DIFFICULT
CIRCUMSTANCES
Nimrod O Bwibo, Mary Shilalukey Ngoma
258 21 HEALTH EDUCATION, COMMUNICATION
SKILLS AND COUNSELLING
Esther D. Mwaikambo, Amos Odiit

265 22 INTERGRATED MANAGEMENT OF
CHILDHOOD ILLNESS
Kopano Mukelabai,
311 23 APPROACHES TO IMPROVE QUALITY
OF SERVICES FOR HOSPITALIZED SICK
CHILDREN
Stephen N. Kinoti
326 24 NATIONAL HEALTH SECTOR
REFORMS AND HEALTH CARE
FINANCING
Esther D. Mwaikambo, Stephen N. Kinoti,
Amos Odiit, Samuel Ayaya
332 25 BASIC STATISTICS FOR HEALTH
CARE
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Dalton Wamalwa and Jeremiah Banda
[



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CHAPTER 1

PRIMARY HEALTH CARE

Elizabeth Hillman, Kate Wotton, Kopano Mukelabai
“A world that is greatly out of balance in matters of health is neither stable nor secure.
Viewed against current trends, primary health care looks more and more like a smart
way to get health development back on track. Thirty years of well-monitored experience
tell us what works and where we need to head, in rich and poor countries alike.”
Margaret Chan, World Health Report, Oct 2008
Introduction
Like many great and timely ideas, Primary Health Care emerged in several places at the
same time. In China, the success of the barefoot doctors, local village health workers
trained in first aid with a focus on prevention, improved health for rural Chinese on a
grand scale. In South East Asia, the importance of prevention, local midwives,
community involvement and good nutrition was documented in Health in the Developing
World by John Bryant

Africa too was moving towards a focus on more accessible care. In Uganda in the
1960s, Maurice King, a microbiologist teaching at Makerere undertook a locum for a
friend in the Karamoja, a remote region of nomadic people with few health care workers.
It was an eye-opener and led to his collecting a group of like–minded physicians in
Africa for a symposium. From this meeting, a classic text on primary health care,
Medical Care in the Developing World, subtitled a Primer on the Medicine of Poverty
was published. For the first time the relationship between the catchment area of a
health facility and the time it takes to walk to and fro appeared in print. Not
unexpectedly almost 90 per cent of those seeking care from a health unit were drawn
from a radius of less than 5 km – the distance a mother with a child on her back, or a
toddler in tow, could walk in a day. This finding led to a reassessment of the role of
hospitals and the need for more accessible care.

A pediatrician working in West Africa, David Morley introduced the concept of Under- 5
Clinics dealing with mothers and children, who are the most vulnerable members of the
community. In another classic, Pediatrics Priorities in the Developing World, he
pioneered an improved design of such clinics to allow more and better care for children
and their mothers. About the same time, important aspects of nutrition, such as the
onset of kwashiorkor in the older child weaned early when a new child is born, were
identified by the Jelliffes and Cecily Williams.

This set the scene for the WHO, UNICEF and the NGOs to pull together the WHO
Declaration of Primary Health Care in Alma Ata in 1978 with the goal of Health for All by
the Year 2000. At the time there was concern that such a lofty goal was unattainable.
But health workers in the developing world were insistent that the goal was needed and
could be achieved.



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Objectives:
At the end of this session, the student will be able to:
Describe the concept of Primary Health Care.
List 8 elements of PHC
Clarify 8 principles of PHC.
Advocate for community participation.
Learning Activities:
Read the Declaration of Alma Ata, WHO, 1978 Report of the International Conference
of PHC; Chapter 1, UNICEF State of the World, 2008 and World Health Report 2008 on
PHC and Ouagadougou Declaration on PHC and Health Systems in Africa, 2008
Meet with district and local health staff, UNICEF and NGOs to become familiar with
existing PHC programs and available reference materials.
Participate in a community meeting in which community involvement in a PHC issue is
discussed.
Outline a PHC approach to a specific child health issue.

Definition of PHC:
PHC is spelled out in detail in Article VI of the Declaration of Alma Ata.
“Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and the country can afford to maintain at every stage of their development in
the spirit of self-reliance and self-determination. It forms an integral part both of the
country’s health system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the first level of
contact of individuals, the family and community with the national health system bringing
health care as close as possible to where people live and work and constitutes the first
element of a continuing health care process.”
Alma Ata, 1978
Health is defined as a state of complete physical, mental, social and spiritual well
being and not merely the absence of disease or infirmity. These four elements of
well being influence each other. When the influence is positive the individual enjoys
a healthy life. Conversely when the influence is negative the individual suffers ill
health. WHO



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The 8 Elements of PHC

The eight elements or program of PHC spell out MEDICINE and are sometimes referred
to as the New Medicine

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



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





D – Drinkable Water and Safe Sanitation
Lack of clean, drinkable water causes many diseases. Efforts are needed to make
water safe and available for everyone. To result in permanent solutions, women
need to be involved actively in water
projects.

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


For almost all children, the most important primary health care
worker is the mother.
Teaching Other People May be More
Important than Doing it Ourselves.

The Cold Chain

The cold chain refers to the need for
refrigeration of the vaccine while getting
it to the most rural and remote places

New technology developed: temperature
monitors, cold boxes,
Purchase and maintenance of kerosene
refrigerators
Reliable transport system
Retraining of health workers




4
C – Control of Endemic Disease
Endemic diseases are those commonly found in a region. Malaria is endemic in Sub-
Saharan Africa and meningitis is endemic in the meningitis belt of Northern Africa.
Appropriate technology has been identified to assist with control of many endemic
diseases including insecticide-treated bed nets in malarial areas and ORS for
treatment of diarrhea.
I – Treatment of Illness and Injury
Curative care for illness or injury is but one of the eight PHC programs. Care needs to
be provided close to where people live. Appropriate, accessible treatment also needs to
be affordable. In many developing countries poor people now pay two- ten times more
out of the own pocket for their health care than is provided by the government.

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

E – Essential Drugs
Essential drugs are the basic drugs needed to treat
common illnesses and disease in a country. PED
DRUGS NEEDED Most developing countries have 20
drugs for rural dispensaries and health centers and a
somewhat larger but still limited list of drugs for
hospitals. A system to ensure ongoing supply, storage, dispensing and training of
staff is a key part of ensuring provision of essential drugs.
Some countries included other programs into the basic health program list such as
dental care and mental health but all countries had the basic eight PHC elements.







The 4As
Health care and
prevention needs
to address the 4As

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



5
Characteristics of PHC

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

Community Participation
Participation is more than involvement and
is much more than contributing labour and
time although both are often necessary.
Participation means being included in
planning, decision-making, implementation
and evaluation. Through full participation
people grow in knowledge and confidence
and can be empowered to make the
changes needed to improve their health and
that of their families. Participation needs to
involve women and the disadvantaged.

Intersectoral Collaboration
Health is much more than merely the
absence of disease. Health involves the
food we eat, the work we do, the
relationship we have and the education we
receive. To fully achieve health we need to
work collaboratively with those in other
sectors such as education, agriculture,
women’s affairs, local government etc. For
example, what is taught in school can be
improved to ensure children are taught
about important health problems, such as
diarrhoea and how it can be managed using
ORS.

Prevention
Since there will never be sufficient resources to treat all current
and possible diseases, we need to begin to prevent those that
can be prevented. Prevention is not only better for people, it
also saves money. Most people, given the information and
opportunity are more interested in preventing health problems
than dealing with disease.

Appropriate Technology
Appropriate technology is technology which the community
can afford, implement and maintain. It needs to be simple,
effective and scientifically sound so it will be sustainable.
Simple solutions have been provided which prevent many
illnesses. Examples include: Oral rehydration salts; Child to
Child programs in First Aid;
Support Breastfeeding

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



The Tippy Tap used
for washing hands,
delivers small



6
Training of Traditional Birth Attendants (TBA) in prenatal care; Tippy Taps and energy
efficient stoves.

Decentralization
Decentralization of health care puts control back into the hands of the local community.
Decentralization devolves responsibility for health to district health teams and provides
them with the training and the resources to do it.

Integration of Health Services
For the children and their mothers to receive good health care, it is important to provide
all the care that they both need at the same place and time. When a mother has spent
her day bringing a sick child to the clinic, it is important that she be provided with health
education to prevent future episodes, her children are immunized and weighed and
contraception advise and antenatal care are provided if appropriate.

Sustainability
Sustainability is the ability to carry on and maintain services. Attention to sustainability
is needed at the time programs are first put in place, so that once established, they can
be continued. Hopefully many health programs can be sustained by the community with
minimal outside assistance.

Equity and Social Justice
Equity involves more than being equal. It requires that resources be distributed
according to need. Those who have more need for health services should receive
more. Social justice is a way to leveling the playing field for all.







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

Approximately three quarters of health budgets are spent on
doctors and hospitals providing curative care for a small
minority of people, mainly in towns and cities.

Approximately three-quarters of disease in the world is
preventable through primary health care. Primary health care
workers cost a tiny fraction of the cost of training a doctor and
are often more effective in promoting good health.




7












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.



8
“It is in child health that the greatest of all gains can now be made. Today, a solid
scientific consensus stands behind a body of knowledge, traditional as well as modern,
discovered or rediscovered, which can enable most families to prevent as well as treat
almost all the major causes of child death and malnutrition at a cost which they can
afford.”
Halfdan Mahler, WHO
Increasing Relevance of PHC
In calling for a return to primary health care, WHO and UNICEF argue that its values,
principles and approaches are more relevant now and inequalities in health outcomes
and access to care are much greater today than they ever were before.
In far too many cases, people who are well-off and generally healthier have the best
access to the best care, while the poor are left to fend for themselves. Health care is
often delivered according to a model that concentrates on disease, high technology, and
specialist care, with health viewed as a product of biomedical interventions and the
power of prevention largely ignored.
Specialists may perform tasks that are better managed by other health workers. This
contributes to inefficiency, restricts access, and deprives patients of opportunities for
comprehensive care. When health is skewered towards specialist care, a broad menu of
protective and preventive interventions tends to be lost.



Inequities in access to care and in health outcomes are usually greatest in cases where
health is treated as a commodity and care is driven by profitability. The results are
predictable: unnecessary tests and procedures, more frequent and longer hospital
stays, higher overall costs, and exclusion of people who cannot pay.
Fragmented Health Care
In the developing world, care tends to be fragmented into discrete initiatives focused on
individual diseases or projects, with little attention to coherence and little investment in
basic infrastructures, services, and staff. Above all, health care is failing to respond to
rising social expectations for health care that is people-centred, fair, affordable and
efficient.
A primary health care approach, when properly implemented, protects against many of
these problems. It promotes a holistic approach to health that makes prevention equally
important as cure in a continuum of care that extends throughout the lifespan. As part of
WHO estimates that better use of existing preventive measures could reduce
the global burden of disease by as much as 70%.



9
this holistic approach, it works to influence fundamental determinants of health that
arise in multiple non-health sectors, offering an upstream attack on threats to health.
Primary health care brings balance back to health care, and puts families and
communities at the hub of the health system. With an emphasis on local ownership, it
honours the resilience and ingenuity of the human spirit and makes space for solutions
created by communities, owned by them, and sustained by them.
Working Towards Fairness, Efficiency and Compassion
The core strategy for tackling inequalities is to move towards universal coverage in a
spirit of equity, social justice, and solidarity. Fairness, efficiency and compassion in
service delivery especially targeting the most vulnerable populations, should be the
overarching goals.
Primary health care also offers the best way of coping with the ills of life in the 21st
century: the globalization of unhealthy lifestyles, rapid unplanned urbanization,
environmental changes and the ageing of populations. These trends contribute to a rise
in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, which
create new demands for long-term care and strong community support. A multisectoral
approach is central to prevention, as the main risk factors for these diseases lie outside
the health sector.
REFERENCES:
UNICEF, State of the World’s Children, 2008.
Alma Ata Declaration, Report of the International Conference on Primary Health Care,
06-12 September 1978, WHO Bulletin, Geneva 1978
World Health Report 2008, PHC
Ouagadougou Declaration on PHC and Health Systems in Africa, April 2008

“Too many of us still think of medical care systems or interventions rather than thinking
along new lines in order to understand the determinants of the new problems and to
grasp opportunities that reach beyond the health care system….we do not need just a
little bit more health education here and there; we need a new approach to action and a
strong alliance to move us forward.’
Halfdan Mahler



10

Upstream Downstream – a parable

It was many years ago that villagers of Downstream recall spotting the first body in
the river. Some old timers remember how spartan were the facilities and procedures
for managing that sort of thing. Sometimes, they say, it would take hours to pull 10
people from the river, and even then only a few would recover.
Though the number of victims in the river has increased greatly in recent years, the folks of
Downstream have responded admirably to the challenge. Their rescue system is clearly
second to none: most people discovered in the swirling waters are reached within 20 minutes;
many less than 10. Only a small number drown each day before help arrives; a big
improvement from the way it used to be.
Talk to the people of Downstream and they'll speak with pride about the new hospital by the
edge of the waters, the flotilla of rescue boats ready for service at a moment's notice, the
comprehensive health plans for coordinating all the manpower involved, and the large
numbers of highly trained and dedicated swimmers all ready to risk their lives to save victims
from the raging currents. Sure it costs a lot but, say the people from Downstream, what else
can decent people do except to provide whatever is necessary when human lives are at stake.
Oh, a few people in Downstream have raised the question now and again; "What's going on
Upstream? Why are these bodies in the river at all?" But most folks show little interest in
what's happening Upstream. It seems there's so much to do to help those in the river that
nobody's got time to check how all those bodies are getting there in the first place. That's the
way things are sometimes.
Don Ardell
COULD USE AN ILLUSTRATION




11
When teeth are together they can break bones. Ankole proverb

When spider webs unite they can tie up a lion. Ethiopian proverb

The teeth which are together break bone Runyankole proverb

There is a path to the top of highest mountain.

Do not look where you fell, but where you slipped. African proverb

If you don't stand for something, you will fall for anything African proverb

Lack of knowledge is darker than night Hausa proverb

When the drumbeat changes, the dance changes Hausa proverb

Even the mightiest eagle comes down to the tree tops to rest Ugandan proverb

A home without a mother is a desert Eritrean proverb

Elderliness is not a disease, but a richness. Kiganda proverb

Who digs the well should not be refused water. Swahili proverb

When a lion roars, he does not catch game African proverb

“A new model is needed for research in developing countries. A model that promotes
locally applied research that enhances capacity and answers that arise from the
community. It could be called micro-research and be based, like micro-finance, on
small grants for those who have little access to funding opportunities.”

Jerome Kabakyenga, Dean, Mbarara, Uganda and Noni Macdonald, ed. CMAJ







12
DECLARATION BY THE International Conference on Primary Health Care and
Health Systems in Africa, Ouagadougou, Burkina Faso, 28-30 April 2008

The Conference held in Ouagadougou, Burkina Faso from 28-30 April 2008, declare as
follows:

I. Deeply concerned by the many public health challenges that our continent is facing
including:
- The high burden of disease;
- The weakness of health systems with inadequate social protection and
insufficient financial and human resources for health, a situation worsened by
brain drain;
- The widespread poverty among the majority of the population;
- The impact of armed conflicts and violence;
II. Recalling the Alma-Ata Declaration of September 1978 inviting all governments
and the international community to protect and promote the health of all peoples of
the world;
III. Recalling the declaration by Heads of State and government of the Organization of
African Unity at its 23
rd
Ordinary Session in Addis Ababa in 1987 on health as the
bedrock of development;
IV. Recalling the commitment made by Heads of State of all countries in the world in
September 2000 to achieve by 2015, the eight Millennium Development Goals four
of which are related to health;
V. Recalling Regional Committee Resolution AFR/RC50/R1 passed in Ouagadougou
in 2000 on Health-for-all Policy for the 21
st
Century: Agenda 2020;
VI. Recalling Resolution AFR/RC52/R5 adopted in Harare in 2002 on the strategy for
accelerating the development of human resources for health and document
AFR/RC57/9 on development of human resources for health in the WHO African
Region: Current situation and way forward;
VII. Recalling Resolution WHA 58.33 urging Member States to ensure sustainable
financing for health, universal coverage and the social security system;
VIII. Recalling the commitment that OAU Heads of State and Government made in
2001 on HIV/AIDS, tuberculosis, malaria and other related infectious diseases
during the African Summit in Abuja to allocate 15% of national budgets to health;
IX. Recalling Regional Committee Resolution AFR/56/R6 adopted in Addis Ababa in
September 2006 on revitalizing health services in the African Region using the
Primary Health Care approach;
X. Recalling Regional Committee Resolution AFR/RC56/R5 passed in Addis Ababa in
September 2006 on health financing: a strategy for the African Region;
XI. Recalling the Addis Ababa community health declaration of November 2006 urging
States to create an environment conducive to the development of community
health and take concrete action to strengthen health systems;



13
XII. Recalling the declaration by the third ordinary session of the African Union
conference of ministers of health in Johannesburg in April 2007 urging Member
States to commit themselves to inter-ministerial collaboration for coordinated,
harmonized and comprehensive response to the health challenges that Africa is
facing;
XIII. Recognizing the link between health, poverty reduction, good governance, peace
and security, gender integration and global commitment to universal access to
PHC in order to facilitate the achievement of the Millennium Development Goals;
XIV. Considering that a healthy population is not only a development imperative but
also a wealth for African countries;
XV. Considering the scarcity of resources for health in African countries;
XVI. Recognizing that notwithstanding efforts by countries, there remain challenges
such as poverty, bad governance, low participation of communities especially
women in decision-making process, weaknesses of health delivery systems
including inadequacy of motivated and qualified human resources, limited
capacity in care provision, weak interface between the community and the formal
systems of health delivery resulting, very often, from lack of health awareness;
XVII. Recognizing that Africa will need to make increased efforts before it can achieve
the Millennium Development Goals;
XVIII. Aware of the multidimensional nature of health, the importance of, and need for,
intersectoral collaboration both internally and externally in order to improve the
health status of the populations;
XIX. Realizing the historic opportunity provided by the interest shown in, and
importance attached to, health as a factor of development.

The Conference:
1. Reaffirms the relevance and validity, today, of the basic principles
and elements of the Alma-Ata Primary Health Care Strategy;
2. Makes a commitment to promote systematically the involvement
and increased participation of communities in health development
in order to facilitate the achievement of the Millennium
Development Goals and improve the well-being of the peoples of
Africa;
3. Strongly recommends;

1. To governments:

(a) To establish mechanisms for effective implementation of previous resolutions,
declarations and other commitments to strengthen health systems and
implement PHC;
(b) To undertake internal and external advocacy for revitalizing the PHC strategy
in order to strengthen health systems;
(c) To accelerate the process of decentralization and deconcentration within the
health system in order to meet the expressed needs of the populations;



14
(d) To revitalize or establish an appropriate coordination mechanism that brings
together the inter-ministerial committee, national health committees and other
institutions with a view to harmonizing the complementary roles of the various
levels of the health pyramid;
(e) To incorporate, in their national and district plans, priority interventions for
revitalizing health services based on the PHC approach;
(f) To implement a programme of action to address the human resources for
health crisis including effective deployment, stimulation of better performance
and adequate response to brain drain;
(g) To strengthen planning and training with emphasis on public health,
employment and human resources management and retention;
(h) To allocate resources in an equitable and sustainable manner based on the
needs of the different levels of the health system;
(i) To promote intersectoral collaboration and public/private partnership including
civil society in order to achieve the Millennium Development Goals;
(j) To revitalize referral systems to support integrated district health services;
(k) To mobilize and bring together all development actors to enhance
cohesiveness and synergy in the choice and delivery of the planned
integrated services;
(l) To formulate strategic health financing policies and plans fitting into the
overall national development framework especially as regards medium-term
expenditure and poverty reduction;
(m) To ensure that the financing plan is included in the national socioeconomic
development plan;
(n) To promote health awareness among the population and strengthen the
capacities of communities to provide for their own health care and be more
involved in health activities;
(o) To ensure more effective monitoring, oversight and evaluation of health
activities;
(p) To promote operational research on health systems in a manner that will
facilitate evidence-based decision making;
(q) To establish mechanisms and conditions that would enable ministries of
health to perform their role of leadership, regulation and good governance;

2. To communities:

(a) To organize themselves to take ownership of the management, protection
and promotion of their own health;
(b) To be more involved in monitoring and feedback in regard to health services
delivery and support within communities;



15
(c) To do advocacy among members of the Diaspora for their effective
involvement in development activities.
3. To sub regional, regional and international partners:

(a) To support the implementation of health development policies and plans in
response to expressed needs;
(b) To commit themselves to proving technical and/or financial support in the long
term to ensure sustainability of health actions;
(c) To increase investments in health systems strengthening;

4. To governments and development partners:

(a) Governments should create, at national level, the conditions (meetings, laws,
regulations, etc.) needed to translate into concrete deeds the orientations
contained in the reference document and the recommendations of the
conference to improve the health status of the populations;
(b) Governments and partners should establish mechanisms to follow-up on the
recommendations of this conference;
(c) The WHO Regional Office for Africa should produce a report each year for the
Regional Committee and partners on the progress in the implementation of
the recommendations of the conference;
(d) Governments, in collaboration with partners, should document best practices
and encourage the dissemination and sharing of best experiences among
countries of the region;









16
CHAPTER 2

CARE OF NEW BORN

Rachel Musoke, Mary Shilalukey Ngoma, Aggrey Wasunna

INTRODUCTION
The fourth millennium development goal (MDG) focuses on reduction of the under five
mortality. Many of the programmes that have contributed to the survival of the child
under five years have omitted the neonatal period. As a result 38% of all deaths in the
first 5 years are in this period. If we do not address the problems of the neonate we
are unlikely to meet the global goal improving child survival. Improved survival will thus
depend on investment in interventions that cater for newborn care. Within the neonatal
period the highest deaths occur in the first 24 hours (25-45%) and up to 75% of deaths
occur in the first 7 days. Many of these deaths are also related to the health of the
mother. This is the basis of continuum of care approach for mothers, newborns and
children (pregnancy, delivery and postnatal care).

Health care should start with the girl child ensuring adequate nutrition and growth
followed by cultural changes and life skills that enable the girl to prevent adolescent
pregnancy. All pregnant women should get good care during pregnancy and delivery.
The aim of care is to ensure intact survival of the mother and her baby. Many problems
in this period lead to permanent disability. Majority are predictable. Care starts in the
community but there should be a close liaison with the health facility. The SEARCH
project, India, Gadchiroli, provides a good example of a culturally appropriate, evidence
based community newborn care initiative from which many countries can learn, adapt
and replicate.

Though for child survival we tend to stress goal 4 of the MDG all other goals are equally
important. For you cannot improve child survival without reducing poverty (goal 1),
improving education and equity of women (goals 2 &3), maternal health (goal 5) as well
as reducing infections in the mother (goal 6) and environmental sustainability (goal 7)
Objectives

At the end of this chapter the student should be able to:

Define all terms used in the neonatal period
Describe maternal health and education and their effect on the foetus and baby
State principles of antenatal and perinatal care
State principles of neonatal care
List common causes of morbidity and mortality in the neonate
Outline strategies that will reduce morbidity and mortality
Recognize a sick neonate
Organize neonatal services in a district
Counsel and communicate with parents about baby care






17
LEARNING ACTIVITIES

Examine and be familiar with a normal newborn
Recognize and infant with birth asphyxia and be able to resuscitate such a baby
Recognize, refer or treat and prevent infections of the newborn
Learn principle of cord care
Be familiar with ways of keeping baby warm
Observe and participate in different methods of feeding
Recognize other common features of a sick neonate
Plan care of low birth weight babies
Plan neonatal services in a district

Definitions
Newborn (neonate)/neonatal period: age/period 0-28 days of postnatal life
Early neonatal period: 0-7 days of postnatal life
Late neonatal period: 8-28 days of postnatal life
Preterm baby: <37 completed weeks of gestation
Low birth weight (LBW): birth weight <2500g
Small for gestational age: birth weight <10
th
percentile for gestation
Perinatal mortality rate: stillbirths + 7 days postnatal deaths per 1000 births
Neonatal mortality: deaths in the first 28 days per 1000 live births

MATERNAL HEALTH & EDUCATION

Delay/space pregnancies
Babies born to young mothers tend to die (most of these pregnancies are unplanned).
For healthy outcome for mother and baby the inter-pregnancy interval should ideally be
at least 24 months and preferably 36 months. There is thus a need to find ways of
providing family planning services to the majority of families

Nutrition
Pre pregnancy:
Ideal is to have a well nourished woman before start of a pregnancy. A stunted child will
lead to a stunted adult. Short women have difficulty deliveries. Micronutrient deficiency
especially folate may lead to neural tube defects.
During pregnancy:
Macronutrients predispose to LBW
Micronutrients (in particular iron, zinc, vitamin A, folic acid and iodine) lead to LBW, birth
defects, pregnancy losses, increased infections.

Infections

During pregnancy:
These may lead to foetal infections, intrauterine growth restriction, and preterm labour
or foetal loss
During labour and delivery:
Baby is likely to pick infection especially if there is prolonged rupture of membranes.




18
Maternal Education

This is key for access and utilization of health services as well as self care and care for
the baby.

PRINCIPLES OF ANTENATAL & PERINATAL CARE

Antenatal care (ANC)

This is a good entry point for health care. About 70% of women in Africa attend ANC at
least once during pregnancy. If 90% of women received good quality ANC up to 14%
newborn lives would be saved. It is important for health workers in the community to
know and record all women who are capable of becoming pregnant and to closely follow
up those who are actually pregnant. Women need to be encouraged to attend antenatal
care as early as possible.

Focused antenatal care aims to respond to the needs of pregnant women with
emphasis on:

Adequate nutrition for the mother
Immunization against tetanus (2 doses in first pregnancy, one for each subsequent
pregnancy to a maximum of 5 doses)
Preparation for breastfeeding
Identification of women at risk of poor pregnancy outcome and referring them to
equipped delivery units
Treatment/control/prevention of pregnancy disorders (e.g. PET)
Screening and appropriate care for HIV infection
Birth and emergency preparedness at home
Advice and support to develop health seeking behaviours
Avoiding harmful practices during pregnancy
Being aware of danger signs during pregnancy and child birth and seeking for help
early. Danger signs during pregnancy include:
Bleeding from the vagina during pregnancy
High blood pressure and severe headache
High fever
Swollen hands and face
Convulsions
Labour and delivery
Presence of a skilled attendant at each delivery to support a clean and safe delivery as
well as immediate care of the baby
Availability of transport and referral between community and health care facility
Emergency obstetric preparedness and prompt referral when severe complications
arise. These include:
Prolonged labour
Breech position
Preterm labour
Teenage pregnancy
HIV positive mother



19
PRINCIPLES OF NEONATAL CARE

The normal neonate
Birth weight 2500-4000g Average 3100-3200g
Head circumference 33-37cm Average 34-35cm according to sex
Length average 50cm
Gestation 37 – 41 weeks
Posture is fully flexed when awake
Sleeps most of the time; waking up at 2-3 hourly intervals usually when hungry

Survival of a newborn baby depend these principles
Proper resuscitation/care at birth
Ascertain the adequacy respiration
Provision of warmth
Prevention of infection
Early initiation and establishment of adequate breastfeeding

Proper Resuscitation/care at birth
Emphasis in neonatal resuscitation is on: drying, stimulation and covering to prevent
hypothermia followed by airway and breathing. Room air is as good as oxygen in
neonatal resuscitation. Drugs are rarely necessary.
Basic equipment includes a mucous extractor for clearing the airway. Use of a bag
valve and mask may be necessary if baby is not breathing.

Establishment of adequate respiration

Majority of babies do manage to establish breathing without help. That first cry is so
vital. It opens up the lungs with a high pressure. But when this does not happen we all
panic and may do more harm than good for the survival of the baby. Since asphyxia is
not always predictable preparedness is essential. All persons conducting a delivery
should be able to adequately resuscitate a baby.
Keeping the baby warm

All neonates need extra warmth at birth but care should be taken not to overheat them.
LBW infants, asphyxiated babies and all sick babies in general are at more risk than
normal term neonates.

1. At birth
Babies lose heat very quickly because they are wet at birth. Therefore dry them quickly
remove the wet towel and wrap in a dry one. Put the baby next to mother and if possible
initiate skin to skin nursing (kangaroo care). Delay bathing the baby till after 24 hours of
age. Initiate breastfeeding within 30-60 minutes of birth.
For preterm or low birth weight babies, continue with Kangaroo care to keep them
warm.

2. Care beyond the delivery room
Normal neonate: cover most of the time and keep near mother as much as possible



20
Preterm/LBW depend on size and whether well or sick. Well preterm do very well in
continued kangaroo care. Sick ones should be managed in a warmed up area. If there
is a good follow up programme these babies can be discharged fairly early.
In neonatal units heated rooms with a covered baby can be adequate to keep the
babies warm. Incubators are best reserved for sick neonates in large hospitals with
appropriate back up services. They are expensive, difficult to maintain and require
constant supply of electricity.

Prevention of infections

Clean delivery (clean hands, clean cutting and tying of the cord, clean cloths/towels for
wrapping the baby).
Appropriate cord care after delivery: Discourage harmful cultural practices; Use surgical
spirit until cord drops off and complete umbilical healing
Initiation of breastfeeding within the first hour of delivery
Reduce overcrowding at health facility partly by avoiding unnecessary admissions and
early discharge
Leave baby with own mother all or most of the time
Recognize infected baby and isolate them early. Although clinical features in an infected
newborn can be nonspecific, some of the danger signs include:
Fever or lowered temperature
Too sleepy or hard to awaken
Refusal to feed or feed intolerance
Fast breathing and or chest in drawing
Pus or redness in the umbilical cord and or eyes

Breastfeeding

Initiation of breastfeeding within the first hour plays a major role in neonatal survival. As
we have seen above it helps to prevent hypothermia and infection. It also helps to
establish good breast milk supply and thus the baby will be well nourished from the
start. Babies are born with good reflexes (rooting and sucking) for survival and are able
to regulate their intake to satisfy normal growth. They will demand to be fed when
hungry. If a baby does not demand a feed it usually means he is sick or immature.

If breastfeeding is contraindicated, or the mother is too sick to breastfeed an alternative
suitable breast milk substitute must be available for feeding the baby.

THE LOW BIRTH WEIGHT (LBW) INFANT

It is estimated that in Africa 14% of all babies born are LBW. These babies are either
born too early (preterm) or suffered poor growth in utero resulting from complications
during pregnancy. Preterm babies contribute to about 28% of all neonatal deaths.
Paying attention to their care will thus reduce neonatal mortality. The most vulnerable
are the babies weighing <1500g at birth and < 33 weeks gestation. They have problems
of breathing, feeding and maintaining body temperature and have a higher mortality
than the bigger LBW infants. These very low birth weight (VLBW) are best looked after
in a referral hospital.



21
As mentioned under “keeping babies warm” the LBW over 1500g can easily be kept
warm using kangaroo care method unless they have additional problems. They may
need stabilization for some time in a neonatal unit before being fully transited to
kangaroo care and finally discharged into the community.

COUNSELLING AND COMMUNICATION

This is an area often neglected in a busy health care facility. Imparting knowledge to the
clients is often relegated to the most junior staff and sometimes a student. This should
be a dialogue rather than talking down to the client. All through care information from
the client needs to be discussed so that the client understands what is going on. If a
problem occurred it should be discussed as to how it can be avoided in future. Parents
should be encouraged to seek appropriate care early. The need for continued care at a
health facility should be communicated as well as what will be done.

POSTNATAL FOLLOW UP

Most mothers with normal delivery are discharged from a health facility within 24-48
hours of birth while it is also known that most neonatal problems appear in the first week
of delivery. It is therefore important to plan an early follow up. Depending on the health
care set up in the area this can be a home follow up or at health facility. The first visit is
often planned within 7 -14 days. The earlier the better. At this time it is important to
check:
Adequacy of feeding
Cord/umbilicus for possible infection
Weight gain – should be back to birth weight
The mother should be encouraged to report any concern about the baby as soon as
possible

STRATEGIES TO REDUCE NEONATAL MORTALITY

The common causes of mortality are:
Infections 39% (sepsis, pneumonia, diarrhoea and tetanus)
Preterm global 28% but 50% in Africa
Asphyxia global 23% but 24% in Africa. About 30-50% of deaths occur in the first 24
hours of birth
Almost all these conditions are preventable using simple inexpensive solutions that
have already been outlined in the chapter but let us summarize them. They all depend
on appropriate organization of neonatal care at all levels.

Infections

Treat maternal infection in pregnancy
Giving tetanus vaccine to all mothers
Clean delivery, general hygiene and appropriate cord care
Early recognition and treatment of the infected baby
Early initiation and exclusive breastfeeding
Improving health care seeking behaviour in the community



22
Where community based newborn care programmes exist, training of community based
agents to identify infection and other danger signs in the baby and refer and or provide
care such as antibiotic will save newborn lives.

Preterm babies
Maternal nutrition: adequate intake of both macro and micro nutrients
Improve ANC screening and management of pregnancy complications
Careful care from birth to prevent infections, adequate feeding and kangaroo care when
feasible

Perinatal asphyxia
Screening in pregnancy for those mothers likely to have cephalo-pelvic disproportion
Birth preparedness
Emergency obstetric preparedness and prompt referral
Skilled attendant at delivery for care of the newborn baby

INITIATE BREASTFEEDING WITHIN ONE HOUR OF BIRTH FOR ALL BABIES
UNLESS THERE IS A MEDICAL CONTRAINDICATION. IT SAVES LIVES

ORGANISATION OF NEONATAL SERVICES

This is based on the continuum of care recognizing that most deaths occur at home
during child birth and in the first few days post delivery. Integration into and
strengthening existing services is important. Often reproductive services omit care of
the neonate. But many IMCI programmes have added the ‘N’ (newborn) and ‘C’
(community). In built in this is avoiding of delays – delay in recognition of problems;
delay in transport to reach appropriate care; delay in executing care at the health
facility.

Supportive government policy and planning is needed. Aim at improving health care
systems at all levels. All facilities conducting deliveries should provide essential
newborn care including neonatal resuscitation, care of the moderate low birth weights
infants and establish a good workable referral system.

Skilled attendant at delivery is defined as a health worker trained in managing normal
pregnancy, delivery and immediate postnatal care. He/she should be able to identify,
manage or refer mother or baby with complications. Delivery should take place in a
setting with needed equipment, supplies and drugs as well as transport for
emergencies.

LEVEL 1: HOME/COMMUNITY

Strengthen care at household level by empowering the community to act appropriately.
This could be done through community participation so that the community owns the
programme. Community health workers chosen by the community can be trained to
promote health in the community by providing appropriate information, and identify
babies that need care at a health facility. Studies in India and elsewhere show that a



23
great deal can be done at this level if good training, equipping and supervision is
provided.

They will also be able to:
Advise on appropriate nutrition for the pregnant mother and feeding of babies
Educate on hygiene within the households
Cultivate health seeking behaviour in the community
Recognize problems and encourage families to go for help at the right time
In some cases receive training to identify and treat infection and common life
threatening newborn conditions or refer appropriately

Birth preparedness is important so the community must plan for emergency transport to
the nearest health facility.

LEVEL 2: DISPENSARY/HEALTH CENTRE

Staff: Primarily run by nurses, midwives, and clinical officers (medical assistants) Some
have basic laboratory services requiring a laboratory assistant. If available a nutritionist
would be desirable.
Duties:
Supervision and education of the community health worker
Health care delivery service to the surrounding community
They should be able to:
Provide antenatal care and delivery services to women within the catchment area
Deal with simple problems in pregnancy labour and delivery
Resuscitate a new born baby (All workers)
Do routine tests for antenatal mothers
Identify and initiate treatment in conditions that require hospital care
Supervise care of the neonate in the community

At all times the health care provider should be asking two questions: one - am I trained
to deal with the problem at hand? two – do I have the equipment or supplies to deal
with the problem? If the answer is “NO” to either of these the mother/baby should be
referred to the next station that is able to handle the problem.

LEVEL 3: DISTRICT HOSPITAL

Staff: Doctors, nurses, midwives, clinical officers laboratory technologists (in some
countries obstetricians and pediatricians may be available)
They should be able to provide comprehensive emergency obstetric and neonatal care.
There should be good communication with all the dispensaries and health centres within
the district.

In addition to what is offered at level 2 of care they should be able to:

Deal with complicated problems in obstetrics and paediatrics
Have a neonatal unit for care of sick and low birth weight babies
Supervise the staff at dispensaries and health centres



24
Collect analyze useful information and plan for intervention at different levels
Have a good triage system that will recognize emergency neonatal problems

LEVEL 4: REGIONAL CENTRE

This can be a provincial or a teaching hospital (in some countries the teaching and
referral hospitals are graded higher than a provincial hospital)
All levels of specialists preferably with neonatologists and neonatal nurses are usually
available.
There should be good diagnostic services.
They would be responsible for
Care of normal cases within the catchment area of the hospital
More specialized care
Training of all cadres of health care workers
Supervision and liaising with staff in the lower hospitals
Operational research (especially for teaching hospitals)

BEYOND SURVIVAL

Many babies survive the neonatal period but remain with disabilities that could have
been prevented. These should be minimized and if they do occur intervene early.


REFERENCES

The Lancet 2005: Series on neonatal survival Vol. 365 pages: 821-26, 891-900, 977-
988, 1087-98

THE PARTNERSHIP: Opportunities for Africa’s Newborns. Practical data, policy, and
programmatic support for newborn care in Africa

WHO World health report 2005: Make every mother and child count
Home based care for Mothers and Newborns-A Facilitator Guide for training community

Health workers – UNICEF /ESARO, September 2007

Baseline Knowledge Attitude and Practice Survey for the Community Based Newborn
and Maternal Child Health Initiative in Zambia, MP Shilalukey Ngoma, P Kalesha, RK
Mbewe, Tesfaye Shiferaw, RK Mwale, W. Mutale, C. Chabala, C Michelo, S.Sizya, K.
Mwinga, N Mugala, G Gundumure, D Kaluba Chinyama, D Mumba and V Mukonka.,
UNICEF /MOH Zambia, 2008










25
CHAPTER 3

INFANT AND YOUNG CHILD FEEDING (IYCF)

Rachel Musoke, Ruth Nduati, Aggrey Wasunna

INTRODUCTION
IYCF covers the feeding of the child for the first two years of life. Children have the right
to adequate nutrition as stated in the Convention on the Rights of the Child. For the
young child this means exclusive breastfeeding for the first six months and continued
breastfeeding for two years together nutritious complementary foods.

Why do we want to invest in infant and young child feeding?

Malnutrition is directly and indirectly associated with increased morbidity and mortality of
infants and young children. Inadequate feeding in the early years is a major contributor
to poor economic development. Metabolic programming which is defined as a stimulus
or insult applied at a critical or sensitive period in development, could have long term
effect on structure or function of the organism. Early nutrition has a great impact on a
number of body systems and of critical importance is the brain growth. Brain growth is
highest in foetal life; by the age of 1year it is 60% of adult brain size and by 2 years of
age it is 80%. Poor nutrition in these periods leads to irreversible changes that cannot
be corrected by better nutrition later in life when the effects manifest as suboptimal
education performance and reduced lifetime earnings by >10%. Good nutrition
therefore protects foetus, infant and young child from permanent physical and
intellectual stunting.

Malnutrition underlies up to 60% of the deaths of children aged < 5 years. It is
estimated that up to 20% of these deaths maybe averted by universal adoption of
appropriate infant and young child feeding practices. Malnourished children often
become malnourished adults. Babies of malnourished women are at higher risk of low
birth weight, perinatal and neonatal mortality. At the same time malnourished women
may also have inadequate breast milk production. Babies of ill mothers and those who
are orphaned are more likely to be malnourished and have a higher likelihood of dying.
In Africa we are generally grappling with under-nutrition, unfortunately nutritional
recovery from this may lead to increased risk of obesity in later life. Early childhood
nutrition has a direct bearing on three of the millennium development goals namely:

Goal 1: Eradicate extreme poverty and hunger
Indicator: Prevalence of children less than five years of age who are underweight

Goal 4: Reduce child mortality by two-thirds
Indicators: Under- 5 mortality rate; infant mortality; measles immunization

Goal 5: Improve maternal health: Reduce maternal mortality rate by three quarters
This goal does not address maternal nutrition as an indicator but we know that maternal
malnutrition contributes to maternal deaths as well as early childhood nutrition




26

OBJECTIVES

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

Describe the advantages of breastfeeding and outline importance of good nutrition in
early childhood
Describe the anatomy of the breast
Describe the physiology of lactation
Describe the composition (biochemistry) of human milk
Describe the host resistance and immunological significance of human milk
Describe the processes involved in proper management of lactation
Diagnose and manage problems associated with breastfeeding
Define complementary feeding
Describe the process of proper complementary feeding
Describe feeding of children of HIV infected mothers
Take a feeding history and interpret adequacy of diet according to age of infant or child
Describe systems that support, promote, and protect breastfeeding BFHI) as well as
encourage appropriate complementary feeding

LEARNING ACTIVITIES

Visit an antenatal clinic and carry out breast examination with special emphasis on
anatomical variations of breasts and nipples
Visit an antenatal clinic and interview a pregnant woman on knowledge, attitude and
planned practice on breastfeeding and assess the baby friendly hospital initiative (BFHI)
activity of the clinic
Counsel a mother on importance of breastfeeding
Counsel a mother on how to practice exclusive breastfeeding
Visit a postnatal ward and practice positioning and attachment of a newly born baby on
the breast
Visit a newborn nursery (special care unit) and assist in the breastfeeding of sick a baby
Visit a child health clinic and counsel a mother returning to work after maternity leave on
feeding
Visit a local breastfeeding support group and write a report on its activities
Visit a prevention of mother to child transmission of HIV (PMTCT) programme and learn
how to counsel on feeding options for an HIV infected mother.
Take an infant and young child feeding history

DEFINITIONS (according to WHO)
Infant and young child feeding: The whole complex of dietary, behavioural and
physiological process involved in the child’s ingestion of food
Exclusive breastfeeding: All the child’s fluid, energy and nutrients are provided by
breast milk. Vitamins may be added.
Almost exclusive breastfeeding: Use of water or other non-nutritive liquids in addition
to breast milk
Partial breastfeeding: Mixed feeding with breast milk, (other milks) plus other sources
of energy and nutrients.



27
Complementary feeding: Other foods or liquids provided along with breast milk.
Complementary food: Any nutrient –containing food or liquid given along with breast
milk during the period of complementary feeding.
Transitional foods: Complementary foods especially designed to meet the nutritional
needs of young children.
Family foods: Complementary foods that are the same as those consumed by rest of
the family
Weaning: Putting a complete stop to breastfeeding.

BREASTFEEDING

Advantages of breastfeeding

Breastfeeding has nutritional, immunologic and developmental benefits. Breast milk is a
whole food for the newborn and meets all requirements in the first 6 months of life.
Breast milk has several components that promote brain development leading to better
school performance. Exclusive breastfeeding in the first 6 months of life reduces deaths
from diarrhoea by a factor of 7, and pneumonia by a factor of 5. Overall exclusive
breastfeeding prevents 13% of under five mortality. Early initiation of breastfeeding
reduces risk of neonatal death by a factor of 4, i.e. 16% neonatal deaths are prevented
if a baby is breastfed within the first day of life and 22% if initiation within 1
st
hour of
birth. Non breastfed children are more likely to fall sick and be hospitalized than
breastfed ones irrespective of their socioeconomic status. Exclusive & continued
breastfeeding for the first 2 years of life associated with better growth. Breast milk is a
low cost high quality food; it is natural and sustainable resource which offers food
security to the child and protects the environment.

Breastfeeding contributes to the psychological wellbeing of the infant by promoting
bonding between mother and baby. The baby thus feels securely attached to the
mother. Babies who are securely attached are able to re-establish a sense of wellbeing
after a stressful event. Insecure attachment may signal later dysfunctional development
and behaviour. The direct eye-to-eye contact between the baby and mother enables
them to interact meaningfully. Breastfeeding on demand helps the young infant develop
a sense of basic trust as his needs are met consistently. Breastfeeding may reduce
chance of obesity and metabolic syndrome in adulthood.

If the mother exclusively breastfeeds and feeds several times a day and night she can
be protected from another pregnancy. Child spacing favours child survival.

Mother also benefits from breastfeeding as they have reduced risk of postpartum
haemorrhage, breast and ovarian cancer.

Anatomy of the breast (figure 1)

The breast is composed of the main body, areola and the nipple. In the main body are
glandular tissues (alveoli) several of which drain into a milk (lactiferous) ducts. These
ducts dilate in the areola and are known as lactiferous sinuses which finally open into
the nipple. Each alveolus is surrounded by smooth muscles. Milk glands and ducts are



28
supported by fat tissue and it is this fat that is mainly responsible for the size of the
breast. There is also a good blood and nerve supply.

The areola and nipple contain smooth muscles. Each nipple has 15-25 openings. The
areola contains several sebaceous glands (Montgomery glands) which secrete a
substance that has antibacterial and lubricating properties. There is a rich nervous
supply. The skin of the areola and nipple is much darker than the rest of the breast. The
sizes of both the areola and nipple vary in different women.

Figure 1: anatomy of the breast







29
Physiology of lactation
Preparation of the breast for lactation: During pregnancy there is proliferation of the
ducts and alveoli under the influence of pregnancy related hormones: oestrogen,
progesterone, human placental lactogen (HPL) and human chorionic gonadotrophin
(HCG).

Lactogenesis (initiation of milk secretion): Stage I starts about 12 week before
delivery; stage II is the first few days after birth. During pregnancy prolactin hormone
stimulates glandular activity and they begin to secrete colostrum. Though there is milk
production during pregnancy, increased production is inhibited by placental hormones
especially progesterone. Delivery of the baby removes inhibition of prolactin activity
resulting in creased milk synthesis. This process rather than suckling is responsible for
the initial breast milk production. The volume of the milk produced rapidly increases as
the amount of lactose in the milk rises.

Stage III lactogenesis (maintenance of established lactation) this stage of
lactogenesis depends on an intact hypothalamic-pituitary axis regulating prolactin and
oxytocin synthesis and release. These are referred to as the milk production and milk
ejection (let down) reflexes. (see Figures 2 & 3) Sucking and emptying of the breasts
are very important in maintaining lactation. Sucking leads to release of both prolactin
and oxytocin. Prolactin works on the alveolar cells to increase breast milk production
while oxytocin produces contraction of the smooth muscles leading to milk ejection.
When the breasts are not emptied there is a negative feedback mechanism that inhibits
breast milk production.

Factors that affect prolactin secretion/release include:
Stimulants: nipple stimulation, sight of the baby as well as cry, sleep, sexual
intercourse, drugs such as phenothiazides and reserpine
Suppressors: stress, pain, L-dopa, ergot preparations, stilboestrol






















30
Figure 2. Prolactin reflex

Figure 3: Oxytocin reflex


Composition of breast milk

Human milk is tailored to the needs of the baby. It contains proteins, carbohydrates,
fats, vitamins and minerals in forms that are easily digested and assimilated by the
baby. Though composition is divided into stages the changes during the first two weeks
of lactation are gradual. However the first 5 days milk is known as colostrum it passes
through a transitions period and finally becomes mature by 14 days.

Colostrum: a thick yellowish fluid containing less lactose but more protein, fat, fat
soluble vitamins and minerals than mature milk. It is rich in immune factors especially
immune globulins.




31
Mature milk: composition and comparison with other types of milk is shown in table 1.

Water: is the largest constituent in which all constituents are dissolved, dispersed or
suspended. There is enough water that supplies all that the baby needs in the first 6
months of exclusive breastfeeding even for those that live in very hot climates.

Table 1: Composition per 100ml of milk
Constituent HUMAN COW FORMULA
Water (%) 85-87 87 87
Energy (kcal) 65-67 67 65-67
Protein (g) 0.9- 1.1 3.4 1.5
Casein: whey ratio 40:60 80:20 40:60
Fat (g) 3.5- 4.5 3.4-3.7 3.4
Carbohydrate (g) 7.0 4.8 7.0
Sodium (mmol) 6.5/7.0 22- 25 7.0
Iron (ug) 70 70 120

Proteins: Milk proteins are subdivided into casein and whey proteins. The caseins are in
the solid fraction when milk cuddles while the whey proteins remain in the fluid fraction.
Caseins are difficult to digest especially for the young infant. Hence in human milk the
casein: whey ratio starts low at 80:20 but later in lactation changes to 40:60. Mature
cow milk on the other hand has high casein: whey ratio of 80:20.

Fats (lipids): About 30-35% of infant’s daily energy is provided by fats. Most of the milk
fat is in the hind milk. So if the baby does not empty the breast total energy intake may
be low and the baby will fail to gain weight. Human milk has polyunsaturated to
saturated ratio of 1.3:1 while that of cow milk is 1:4. Human milk is rich in the essential
lipids (linolenic and linoleic acids) that are important in brain development.

Carbohydrates: the main carbohydrate in breast milk is lactose although small amounts
of other sugars such as glucose are found. Human milk has higher lactose
concentration than other mammals. Lactose is metabolized into glucose and galactose
which is important in brain development. Lactose facilitates calcium absorption, and
promotes growth of lactobacillus bifidus.

Micronutrients and minerals: Concentrations of these are adequate for the baby
especially in the first six month of lactation. However if the mother is deficient in
micronutrients there may be deficiency in the baby. About 50% of iron in human is
absorbed versus 10% in cow milk.
Digestive enzymes and growth promoters
Human milk contains digestive enzymes and one of the most well described is lipase an
enzyme that facilitates fat absorption.

There are growth factors that promote maturation of the brain and epithelial surfaces.
Molecules similar to those found in breast milk have been developed into drugs to treat
bone marrow failure.





32
Immunologic qualities of breast milk
Babies are born with an immature immune system and rely of passive immunity from
their mother received through active transfer of immunoglobulins in the last trimester of
pregnancy and through breast milk especially colostrum. The latter is often referred to
as baby’s first immunization. During pregnancy there is active migration of immune
competent cells to the breast where they manufacture anti-infective factors based on
the mother’s experience. Breast milk has a wider repertoire of anti-infective factors
compared to mother’s plasma. The anti-infective factors include antibodies, soluble
components like lysozyme, lactoferrin, lipids and milk fat globules as well as live
leucocytes that protect the baby from infection. The components that are there for
protection /information are not digested/ destroyed as they traverse through the
gastrointestinal tract. Breast milk macrophages home in to the Peyer’s patches where
they help promote infant gut mucosal related immunity and in the process may confer
cell mediated immunity. Thus breast milk is unique in prevention of infection. (1) There
is no risk of contamination; (2) there are several anti-infective properties; (3) it induces
immune competence in several body organs (4) it induces maturation of the gut (5)
faster gastric emptying. As long as baby and mother have close contact, mother will
form protective agents or antibodies against any organism on the baby. Baby will
always be protected as long as s/he gets own mother’s milk. But the protective effect
is dose dependent—exclusively breast fed are most protected; partially breast fed are
better off than those who are not breast fed.

MANAGEMENT OF LACTATION
Prenatal period:
Successful breast feeding depends on knowledge, skills and practice of the health
worker as well as the mother/ parents. Mothers/ parents decide on how to feed their
babies during pregnancy or even before. Decisions are often dictated by observation or
culture. However parents should be given the necessary education to enable them
to make a fully informed choice. The aim of the education is to help them breast feed
optimally and avoid difficulties .Building confidence at this stage is advantageous.

Objectives of prenatal preparation
Psychological support / allaying anxiety
Remove myths and beliefs that may hinder breast feeding.
Provide information which assists the mother / parents to choose how to feed her/their
baby.
Provide technical skills needed for successful breast feeding.
Identify and solve problems
Breast examination to identify any past pathology that will interfere with successful
lactation. It is better to anticipate and be ready to deal with the problem than to wait for
difficulties after the baby has come. Past pathology include: severe trauma, burns, or
extensive surgery. Evidence of present pathology e.g. lumps need referral for action.

It is important to remember that there are many normal variations in shape and size of
breast and nipples. Elasticity of the nipple always improves towards delivery time. There
is no need for nipple preparation even when there is inversion. Hoffman exercises and
breast shells have shown no proven value. Rubbing, rolling and pulling are not



33
recommended- they might even induce premature labour through increased oxytocin
release.

Essential Prenatal Education

Maternal nutrition: assess nutritional status and discuss with the mother on the
importance of an adequate diet for her and her unborn baby. Work out ways how she
can achieve this using locally available food. Pregnant women are not able to meet
their micronutrient needs and therefore will benefit from supplementation with multi-
mineral-vitamin mix. Of note anaemic women are at increased risk of pregnancy related
haemorrhage, preterm and low birth weight delivery. Explain why she may need
supplementation

Benefits of breast feeding: start from what the mothers know and fill in the gaps.

Importance of early initiation: discuss why this is necessary and what will happen in
the delivery room in relation to breast feeding. Initiation should be within the first 30-60
minutes of birth. Early initiation is associated with good milk flow and helps to prevent
infection in the newborn. In the first 60 minutes after a delivery, the baby is alert.
Breastfeeding during this period improves attachment and is associated with longer
duration of breastfeeding.

Positioning and attachment: Demonstrate and discuss how this will help prevent
problems such as nipple pain, trauma (crack) and since it ensures adequate breast
emptying it also prevents engorgement. If attachment is on the nipple and not on the
areola, the milk does not flow, resulting in a frustrated baby. Then the baby sucks
harder and the mother ends up with cracked nipples.
Importance of exclusive breast feeding for 6 months: Exclusive breastfeeding means
giving breast milk only, and no water or prelacteal feeds. In the early period many
mothers worry that there is not enough milk. Please assure mothers that the colostrum
is adequate for the infant and early initiation helps milk flow. Mother who have to go
back to work need to plan how they will sustain exclusive breastfeeding. Breast milk is
safe for 3 months if frozen, 72 hours in the fridge and 8 hours at room temperature.
Show mothers how to express breast milk and to develop a plan that best suits them
which may include carrying the baby back to work. Remind them that expressed breast
milk is safe and other people will not be tempted to share it with the baby.

How to assure enough milk: this is achieved through early initiation and on demand
feeding. The more the breast is emptied, the more milk produced. Thus expressing
breast milk if separated from the baby supports sustenance of the supply.

Encourage her to join a community support group: Mother-to-mother support is very
useful in promoting breastfeeding. The health facility can provide opportunity for
mothers of young babies to interact and support each other on infant feeding and other
related matters.
Give the mother written information as much as possible to enable her to remember
what she learnt in the clinic




34
Perinatal and immediate postnatal period

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





Figure 4: Baby’s mouth wide open Figure 5: Good attachment



PROBLEMS IN BREASTFEEDING

Insufficient breast milk (baby < 6 months old)
This is a common complaint from mothers and often by the time they come to the clinic
they have already started giving a baby some supplementary feeding. Common
complaints from the mother are: baby wants to feed too many times; baby cries a lot;
the baby seems to sleep longer when given formula or cow’s milk.
In this case it is important to look at the baby and the mother and ask a few questions:

Is the baby growing well? If ‘yes’ reassure; if ‘no’ then ask the next question:
How is the positioning and attachment? – If not appropriate then the baby may actually
be starving because he is not able to get the breast milk out of the breast. If ‘yes’ then
go to the next question:



35

How often is the baby’s nappy/diaper changed? This can be an indication of amount of
urine passed. If frequent (6-8 times) then breast milk is adequate and therefore
reassure the mother. If less frequent then explore further by asking:
What is her confidence that she can have enough milk? If she has enough confidence
then counsel and encourage her mother to continue exclusive breastfeeding and stop
any supplement if she had already started. If she lacks the confidence then counsel her
on how to ensure adequate breast milk supply.
Other conditions that may lead to a perception of not having adequate milk –
Periods of growth spurts are associated with increased frequency of feeding. In this
case reassure the mother.

Mothers often associate a soft feeling breast with inadequate milk. This is the normal
texture of the breast and she should be reassured that she has enough milk.

Breast engorgement: This is usually due to infrequent and inadequate breastfeeding.
It may also be due to poor positioning and attachment. Correct the positioning and
attachment and advise her to feed the baby frequently. Help mother to relieve the
engorgement by expressing her breasts. She can express until she feels comfortable. It
may be necessary to give her analgesics such as paracetamol. She can also use warm
or cold packs on her breasts to reduce pain. Wearing a comfortable brassier with wide
straps to support but not compress the breasts is useful. Lactating mothers may need a
brassier that is 2 sizes larger than their pre-pregnancy size. Reassure them that the
breasts will go back to normal size when the baby weans.

Mastitis is an infection of the breast that could lead to abscess formation. It commonly
occurs in the second or third week postpartum. It is managed with antibiotics,
analgesics, warm packs and frequent emptying of the breast. If an abscess develops
then incision and drainage should be done in addition to antibiotics.

Cracked nipples: The best management of this is prevention. However if it occurs keep
the nipple dry by exposing it to air; mother can express breast milk and apply it on the
nipple; check for evidence of infection especially candida. The mother may be having
vaginal candidiasis. If there is candida infection then make sure you treat both mother
and baby at the same time. Show mother how to correctly position and attach baby and
encourage frequent breastfeeding.

Flat or inverted nipples: After delivery the mother can now be shown how to pull out
the nipples and attach baby properly. Mothers with truly inverted nipples need more
help. Use of a 20ml syringe can be useful. Remove the plunger and cut off the needle
end making a smooth margin. The mother can the use this to apply negative pressure
which helps to pull out the nipple just before each feed.

COMPLEMENTARY FEEDING
Age 6-24 months is considered the period of complementary feeding. Timely and
appropriate complementary feeding will reduce mortality; prevent weight loss and more
so stunting. This period can be managed well if accurate information and skilled support



36
for the family is provided. More often than not inadequate knowledge about appropriate
food rather than lack of food is the cause of malnutrition.

Biological basis for introduction of complementary foods

Oral-motor development function during the 0-6 month period is designed for liquid
feeding i.e. breast milk. In the second half of the first year jaw and tongue movement,
together with the appearance of teeth equip the baby for other foods other than milk.
These continue to develop during the second year by the end which the primary
dentition is also completed.

Digestion and absorption of complex carbohydrates and fats is suboptimal during the
first 6 months but as the baby grows these improve to allow baby to take a variety of
foods.

Excretory system: Renal function – ability to excrete excess limited. Breast milk has a
low solute load to the kidney.

Nutritional needs: It is now well established that babies have adequate growth up to 6
months without complementary foods. But by 6 months breast milk ceases to give
enough nutrients to babies hence the need to start complementary feeding.

A baby who is ready for complementary feeds will want to breastfeed more frequently.
The stool will decrease in volume and may have green streaks in it. The first step
would be to breastfeed the baby more frequently and if the increased milk supply is still
not sufficient complementary feeds should be introduced. Breast milk is adequate until
6 months of age.

Risks of early complementary feeding

Physiological stress
Incomplete digestion –may lead to sensitization; diarrhoea
Malnutrition – both over & under nutrition can occur
Micronutrient deficiency
Generally a negative impact on health.

So complementary feeding must be:
Timely – introduced when the need for energy and nutrients exceed that provided
through exclusive milk feeding
Adequate – provide sufficient energy, protein minerals and micronutrients to meet the
needs of a growing child (quantity & quality)
Safe – hygienically prepared, fed and stored
Properly fed – given consistently with the child’s signals of appetite and satiety

Very often people talk of a balanced diet when counseling on complementary feeding. It
is important to define what you mean by this. To some people it means taking the
necessary food groups without thinking of quantities. Perhaps we should be talking



37
more in terms of adequacy—this implies that the quality as well as the quantity as
considered.

The process of complementary feeding
Complementary food is best given in its natural state, and use family foods so that by
the time the child is weaned s/he is able to feed from the same pot as the rest of the
family. But the food has to be specially prepared. Initially the complementary feeds are
liquid but not too watery. Consistency should quickly be increased to provide adequate
calories. For a breastfeeding baby start with small amounts (1-2 teaspoonfuls) twice a
day and gradually increase both quantities and frequency.
Remember that:

Whatever you add displaces milk. Whatever you add is most often of lower nutritional
value than milk
Children continue to need breast milk therefore mother should continue breastfeeding
on demand. In the 6-12 months milk should make up to 70% of child’s diet.
Babies of HIV infected women who are weaned at 6 months need animal source
proteins in their diet to meet all their nutritional requirements. Therefore a non
breastfeeding baby requires a minimum of 500mls of other milk through the 6-24 month
period. In poor communities this may be difficult resulting in malnutrition. An AFASS
assessment should be carried out before a mother weans her baby.
Give a variety of foods taking into account the nutrient content of the food used.
Active feeding i.e. assist the child to eat but do not force feed. Talk to the child and use
the meal times as an opportunity for psychosocial stimulation. In the period 9-15months
babies go through a stage of recognizing themselves as autonomous from the mother
and may refuse to eat. Active feeding then becomes a very important strategy of
ensuring adequate nutrition.

Avoid excessive amounts of food. Fat cells are made in the first 18 months of life and
obesity in this period is associated with the same in adulthood.
Food hygiene is very important. Stress hand washing; clean containers; food should be
freshly prepared or fully boiled every time the child is to be fed

HIV AND IYCF
Efforts to promote infant and young child nutrition including breastfeeding were
expected to reduce child mortality, morbidity, malnutrition as well as disabilities. With
the realization of MTCT of HIV through breast milk, many people stopped
breastfeeding promotion. Even worse, exclusive breastfeeding has now become
associated with HIV and many mothers do mixed feeding to prove that they are
not infected.

Significant progress has been made in defining infant feeding practice in the context of
HIV.

Exclusive breastfeeding is the best option for infant feeding for HIV uninfected mothers.
Even in high HIV prevalence regions the majority of women are not infected. Therefore
promotion of exclusive breastfeeding is good public health practice and is an incentive
for women to avoid infection.



38

It is true breastfed babies of HIV infected women are at risk of infection as long as they
are breastfed. This risk is particularly high in women who are newly infected, women
with advanced HIV disease and those with breast disease (cracked nipples, mastitis
etc.) Without intervention up to 20-45% children got infected. The estimated contribution
of breastfeeding is 14-15%.

Replacement feeding will prevent transmission, but is not a safe intervention for the
majority of mothers. Therefore wholesale promotion of formula feeding for HIV
exposed babies is dangerous and bad public health practice.

Prevention of breast milk transmission of HIV can be achieved through several
strategies.

Prevent new HIV infection in pregnant and lactating women.
Judicious use of anti-retroviral drugs-
Women with advanced disease should be put on HAART.
New data shows that use of prophylactic HAART during breastfeeding by women not
needing treatment also reduces breast milk transmission of HIV
Prophylactic ARVs to the infant during breastfeeding may also prevent breast milk
transmission of HIV.
There are ongoing studies to evaluate the safety of prophylactic ARV by mother or baby
and may soon be part of standard practice.
Adoption of safer infant feeding practices

Exclusive breastfeeding -
Good attachment techniques to minimize cracked nipples
Prompt treatment of breast disease and use of heat treated breast milk during such
episodes
Early weaning as soon as a mother is able to provide nutritionally adequate
complementary feeds. Early cessation of breastfeeding ( <6mo) may reduce HIV
transmission but it increases risk of morbidity & mortality (malnutrition, diarrhoea,
pneumonia). HIV infected infants have better survival if breastfed beyond 6 months.
Replacement feeding for women meeting AFASS

The health worker has a moral and ethical obligation to promote appropriate infant
feeding practice. In order to do this, they must help the HIV infected parents make an
assessment of the ‘balance of risks’ with the goals being a living HIV free infant.

The most recent research shows that HIV free survival of infants of mothers who are on
efficacious ARV regimens for PMCT are similar for breastfed and formula fed infants. In
resource constrained settings breastfed infants of women receiving HAART have better
HIV free survival at 12 months of age compared to formula-fed infants.

Counseling HIV infected women on feeding option
The aim of counseling is to ensure adequate IYCF irrespective of the option chosen as
well as minimizing HIV transmission through breast milk.




39
Parents have a right to choose the best feeding option for their child. This should be
based on clear, adequate and unbiased information from a knowledgeable health care
worker. Once the decision has been made, the health worker continues to support and
guide the parents on how to safely practice the chosen method.

As early as 1987 the world health organization’s (WHO) stand has been that the choice
of infant feeding “should take into consideration the socio-economic and ecological
environment of the mother/infant pair and to the extent to which alternatives can safely
and effectively be used.” Subsequent consensus statements from
WHO/UNICEF/UNAIDS/UNFPA have endorsed the same sentiments. The latest
statement of 2006 has the following recommendations: “The most appropriate infant
feeding option should continue to depend on the mother’s individual circumstances;
exclusive breastfeeding is recommended for the first six months of life unless
replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS);
when there is AFASS then avoidance of all breastfeeding is recommended.”

From this statement we can see that there are two options in the first six months namely
exclusive breastfeeding or exclusive replacement feeding. From six months all infants
should receive complementary foods.
All health workers providing services to pregnant women and mothers of young infants
should provide this counseling and support.
Remember to inform the parents that there is no particular intervention in an HIV
infected parent that will reduce transmission to zero otherwise they get very
disappointed when they do everything possible and still end up with an infected child.

Adherence & longer duration of optimal infant feeding practice can be achieved through
high quality counseling. Exclusive breastfeeding is not the norm in most part of sub
Sahara Africa and therefore all mothers need infant feeding counseling support to
achieve best practice. Health workers should avoid stigmatizing exclusive
breastfeeding.

TAKING A FEEDING HISTORY
The purpose of a feeding history is to get to know and understand the client, her
nutritional status, kind of diet is she taking as well as any medical, physical or mental
problems that will impact on breastfeeding.

Does she have previous experience? --Yes/no. If yes:
How long did she breast feed?
What was the duration of exclusive breastfeeding?
Were there any difficulties and if so how did they affect breastfeeding?

Beliefs/culture:
Ask specifically about use of water, juices, and other milks.
Any other hindrances that may have significant influence on breast feeding.

How is she feeding the current child?
Frequency of breastfeeding day and night



40
If not breastfeeding ask why? What other milk is she giving and how does she prepare
it?

Is the child taking any other food or milk? If yes you will want to know what food,
how it is prepared, the amount and frequency and how it is fed to the child. A 24 hour
food recall is often used and if possible food frequency e.g. in a week helps to judge
adequacy of diet.

SUPPORT SYSTEMS
All mothers need a conducive environment that will help them achieve optimal feeding
of their infant and young children. Support will come from: father and immediate family;
community; health professionals and their professional bodies; government and
partners; all working together for the betterment of child survival.

The Working Mother
All women work whether they are stay home mothers or work outside the home.
Whatever work the woman is bound to affect how she breastfeeds her baby especially
during the exclusive breastfeeding period. For each individual woman, the health care
provider discusses how she will be able to combine work with breastfeeding. It may
mean taking the baby to the work place or being able to express/pump her milk for the
period that she is away from her baby. She needs to be guided on how to store the milk
depending on facilities at home.

Maternity Protection for Working Mothers (maternity Leave)
As early as 1919 the international labour organization (ILO) has had regulations on the
working mother with aim of enabling her to take time off around the time of delivery but
able to keep her job. Unfortunately many employers especially those in the private
sector are not happy with this. More recently (yr. 2000) the same organization reviewed
the time and increased it from 12 to 14 weeks. This is an improvement but still does not
cover the six months of exclusive breastfeeding. Hence the addition of two half hour
nursing breaks per day especially during the period of exclusive breastfeeding. The
convention passed in 2000 is yet to be ratified by many countries. Find out how your
country treats maternity leave. Developing a baby/mother friendly work place will help. If
employers are educated on the value and advantage of breastfeeding they can help
their employees manage exclusive breastfeeding by either allowing time off or bring the
baby to work

The Baby Friendly Hospital Initiative (BFHI)
In 1889 UNICEF and WHO endorsed a document known as Protecting, promoting and
supporting breast-feeding: The special role of maternity services. In it were “The Ten
Steps to Successful Breastfeeding.” This document and the Code form the basis of
BFHI. To emphasize the importance of the mother some countries have added ‘M’ –
BMFHI. A hospital that practices these steps is assessed by independent assessors
and if satisfied the hospital is then designated to be baby friendly. Thereafter continued
self assessment with occasional external assessment helps the facility to remain
friendly.





41
Community breastfeeding support group
This could be a group purely for breastfeeding activities but for sustainability purposes it
may be better to incorporate other activities the group may want to address. Both IMCI
and BFHI strongly recommend community support with the realization that IYCF is
actually a community activity. Health workers at facilities should be knowledgeable on
the activity of the community and work with them for health promotion. If there is no
active community support for breastfeeding then the health worker is encouraged to
start one. But it is very important that the community own the group the health worker
just being an expert advisor. Here experienced and knowledgeable (check accuracy of
this knowledge) women help to support breastfeeding mothers through dialogue and
sharing. The role and support of men and fathers is emphasized. Community support
leans heavily on advocating for behaviour change.

The International Code of Marketing Breast milk Substitutes
The Code was endorsed by the World Health Assembly in 1981. The code and
subsequent resolutions seeks to encourage and protect breastfeeding and to control
inappropriate marketing practices used to promote products for artificial feeding. The
code applies to artificial milk for babies (formula), other products used to feed babies
especially when they are marketed for use in a feeding bottle. The code also applies to
bottles and teats. Each member country was required to adopt and enact a law based
on the articles of the International Code. There should be a place where violations are
reported as well as penalty. Unfortunately many countries are lagging behind but that
does not stop health care providers from using it to promote breastfeeding. Various
articles of the code apply to mothers /parents (public), health care workers and their
health care facilities, as well as the manufactures their agents and indirectly to the
shopkeepers.

Global Strategy for Infant and Young Child Feeding
“WHO and UNICEF jointly developed this strategy to revitalize world attention to the
impact that feeding practices have on nutritional status, growth and development, health
and thus the very survival of infants and young children.” It encourages all concerned
parties to take it seriously and be committed to protect the health and nutritional well
being of infants, young children, pregnant and lactating women. It is practical and allows
everybody (individuals, health facilities and organization) to be actively involved.

Hospital & National policies and strategies
All the above support systems will not work to the maximum without government
commitment. Health workers are encouraged to support and urge their governments to
formulate policies and laws that will enhance child survival. But even without laws health
care facilities can go a long way in improving infant and young child feeding. Financial
commitment is also very important. Find out what policies are operational in your
country.

“ The global strategy includes as a priority for all governments to ensure that the health
and other relevant sectors protect, promote and support exclusive breastfeeding for six
months and continued breastfeeding up to two years or beyond, while providing women
access to the support they require – in the family, community and workplace to achieve
this goal”



42

REFERENCES

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
































43
CHAPTER 4

CHILD NUTRITION

Ruth Nduati, Ahmed Laving, Heena Hooker, Peter Ngwatu

INTRODUCTION
Good nutrition is essential for satisfactory physical growth and mental development,
provides reserves for stress, as well as prevention of acute and chronic illnesses.
Compromised nutrition during childhood has lifelong effects on the well being of
individuals. The window of opportunity for prevention of these effects is during
pregnancy and the first 2 years of life. After two years, malnutrition will have caused
irreversible damage.

Unfortunately under nutrition is common especially in the developing countries. Four
fifths of under-nourished children are found in 20 countries of Africa, Asia, Western
pacific and the Middle East. The most important problems are (i) stunting, (ii) severe
wasting and (iii) intra-uterine growth restriction.

Under nutrition underlies 3.5million child deaths annually. The risk of death increases
with severity of malnutrition. Seven of 10 countries having the highest under-five
mortality are in Africa and include Democratic Republic of the Congo, Nigeria, Ethiopia,
Uganda, Tanzania, Madagascar and Kenya.

This chapter will outline the essential nutritional requirements of children, causes of
malnutrition, discuss the proven effective public health interventions and address the
management and prevention of common nutritional disorders.

OBJECTIVES

At the end of the chapter, the learner should be able to:
 Understand the basic nutritional requirements for optimal growth
and development.
 Discuss the conceptual framework on the causes of malnutrition
 Outline causes of child hood malnutrition
 Discuss the impact of childhood malnutrition
 Outline public health interventions to reduce the high prevalence of malnutrition
 Assess the nutritional status of a child.
 Describe the management of severe malnutrition.
 Describe the aetiology, diagnosis and treatment of other common nutritional
problems.
 Discuss nutrition management of HIV infected children as a model of nutrition
management during chronic illness.

LEARNING ACTIVITIES

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



44
- Identify a child who is not growing well and counsel of adequate feeding using
foods available to the care give
- Participate and write up the care of a child with acute severe malnutrition. Give
nutritional advice
- Assuming you are visiting a primary school plan a group discussion with
the children. You can do this with your peers acting as school children
- Plan a diet for a 7 year old HIV infected child who is having moderate
malnutrition

NUTRITIONAL REQUIREMENTS OF CHILDREN
Individual nutritional requirements vary with age, genetic and metabolic differences.
There are basically five different types of nutrients (plus water), all of which the body
needs in differing amounts for its various functions.

Water
Water requirements will vary with environmental temperature, activity and caloric
consumption. Daily requirements are 60-100mls/kg at birth and increase with age to
150mls/kg/day by end of the first week of life. Exclusively breast fed babies do not
require extra water as breast milk contains 80-90% water.

Carbohydrates
These provide the main source of energy for body functions. Daily intake should be
about 60 grams per 24 hours (0–6 months) and up to 130 grams per 24 hours at 3
years. Dietary sources include breast milk, sugar, and cereals such as maize, wheat,
oats, millet, starchy roots and fruits.

Fats
Fats have high energy and form an important energy store. They help to absorb fat
soluble vitamins. About 30% of the total energy required should be derived from fats.
Foods rich in fat include oils, margarine, butter, fish, meat, chicken, cheese, groundnuts
and soy bean. It is best to use vegetable fats (oils) as they generally contain
unsaturated fats which are better for the body than saturated ones.

Protein
Proteins are essential for growth and repair of tissue cells, synthesis of haemoglobin,
enzymes and antibodies. Important sources of protein include milk, eggs, fish, poultry,
cheese, soybeans, peas, lentils and nuts. Breast milk is the single most important
source of protein during infancy.

Vitamins
These include Vitamins A, B group, C, D, E and K and are also known as
micronutrients. These are consumed in small quantities and they have varying
physiological roles in the body. Important sources of vitamins include milk, vegetables,
grains, fish, liver, nuts and fruits







45
Minerals and trace elements
Also grouped under micronutrients, these include sodium, potassium, calcium,
magnesium, zinc, iron and iodine consumed in small quantities but essential for the
healthy functioning of the body. These are present in most foods mentioned above.

Energy requirements
Children require energy for growth, physical activity, basal metabolism and heat
production. The energy requirements vary depending on the age and activity of the
child. The average requirement for the first year is about 80-120 kcal/kg/day and
decreases in the subsequent years but increase during adolescence. Each gram of
protein or carbohydrate provides 4 kilocalories whereas a gram of fat provides about 5–
9 kilocalories.

The Food Pyramid – a Tool for Healthy Living
We buy and cook food as opposed to nutrients. The food pyramid has been formulated
to translate nutrient requirements into foods and a general guidance for daily planning of
the menu. The childhood food pyramid used in USA gives guidance on feeding
children aged 2-5years and 6-11 years. This can be adapted to local foods in other
countries The Food pyramid is based on 6 food groups as listed in table 1

Table 1: Recommended food helpings for adults and children
Adults and
adolescents*

6-11 years

Grain group 5-11 servings 6 servings
Vegetables 3-5 servings 3 servings
Fruits 2-4 servings 2 servings
Meat, beans, fish, peas, nuts, and
seed
2-3 servings 2 servings
Milk Yoghurt and cheese group 3-5 servings 2 servings
Fats and oils, sweets/sugar Use sparingly Eat less

NB 1 serving = 1 whole fruit, 125mls of juice, 1 eggs, 30g of meat, 150g of fish, 1 cup of
cooked rice or ugali, 1 chapatti, 1 slice of bread, 1 medium potato, 1 medium glass of
milk, 1 cup leafy green vegetables, ½ cup cooked vegetables, ½ cup cooked legumes
(peas, beans), 2 table spoonfuls of nuts, etc.

Ideally these foods should be packaged into 3 main meals and 2 snacks.

General principles in selection of foods
Cereals (wholegrain), roots and starchy fruits (plantain & cooking bananas) besides
providing energy have good fibre content.
Vegetables should be steamed/boiled 5-10minutes, in as little water as possible to
minimize losses of vitamins and minerals
Fruits should be served raw or made into juice. Whole fruits are preferred to juice.
Milk is crucial as source of calcium for the growing child. Cabbage, cauliflower and
broccoli are good plant sources of calcium but nothing near milk and dairy products.



46
Meat-important sources of iron and zinc minerals, high quality protein. Spinach and
legumes are also very good sources of iron.

Mixing legumes with cereals is desirable e.g. maize and beans. Legumes are deficient
in methionine and rich in lysine while grains are deficient in lysine and rich in
methionine. Therefore eating either at the same meal or during the same day gives a
very good source of proteins comparable to consumption of animal protein. Legumes
need to be cooked thoroughly to increase bioavailability of these nutrients. If they are to
be prepared for complementary food for babies they should be pre-cooked before
milling.

Children aged < 2 years
The learner should review the chapter on infant and young child feeding.

2-5 years (Pre-schoolers)
To help children develop healthy eating habits parents should set an example.
Although children are erratic eaters, they should be allowed to determine the amounts
they wish to eat within reasonable limits and not be forced to empty their plates. This
avoids fights at meal times which may either result in under or over eating both of which
are undesirable. Regular growth monitoring is essential to ensure the child is growing
well.

6-11 year olds (school children)
The key messages in the children’s food pyramid are:
Be physically active every day. This is at least an hour of moderate to vigorous
physical activity every day.
Choose healthier foods from each of the food groups every day.
Eat more of some foods groups- vegetables, fruits, grains and a source of calcium.

Adolescents
This is a period of increased nutrient needs, but in the background of peer pressure,
consciousness of physical body image and media makes adolescence quite vulnerable
to malnutrition. They should be encouraged to feed well according to the food pyramid.

In resource constrained settings few children are able to achieve the above
recommendations. The biggest challenge is to achieve adequate intake. In addition the
children have to walk long distances to and from school and are likely to go to school
hungry. Also for part of the time the children are in school and parents may be unable to
influence what the child eats. Teachers therefore are also important especially if food is
provided by the school.
On the other hand there are increasing numbers of children from affluent families who
are beginning to suffer from obesity and for whom these guidelines will help prevent
further progression.

HELPING FAMILIES TO EAT WELL
This includes addressing a number of issues some of which are listed below:
- Produce or buy a variety of food for the family (demonstrate with gardens,
discuss good buys, food storage)



47
- Pregnant and lactating women should be well catered for
- Adequate breastfeeding and complementary feeding.
- Share food well so the small children are not competing with older family
members
- Encourage diversity of foods eaten within the household
- Good preparation to prevent loss of nutrients
- Teach school children and adolescents about good eating habits, how to prepare
and store food
- Work with school teachers to ensure good feeding while children are in school
- Early and adequate care /treatment of illnesses
- Growth monitoring especially of young children. The growth chart easily picks out
those growing well, or not thus enabling early interventions to forestall
progression to severe malnutrition

NUTRITIONAL DISORDERS

Definition
Malnutrition is broadly categorized into under-nutrition and over nutrition (over weight
and obesity). Under nutrition encompassed stunting, wasting, deficiencies of vitamins
and minerals (collectively referred to as micro-nutrient deficiencies).

Indicators of malnutrition
 Hunger, the feeling of discomfort from not eating is a good indicator of food
security. One of the Millennium development goals is to reduce by half the
number of people who suffer from hunger.

 Wasting – low weight for height indicates acute weight loss.

 Stunting – low height for age indicates chronic malnutrition.

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

 Maternal short stature and low body mass index during pregnancy and lactation.
The learner should review the chapter on growth monitoring for a detailed
discussion on the anthropometric techniques.

Conceptual framework of the causes of malnutrition

Causes of malnutrition are categorized into:

(i) immediate,
(ii) underlying and
(iii) basic causes.

Immediate causes of malnutrition include poor diet, and disease;




48
Underlying causes include inadequate care of children and mothers, household food
insecurity, unhealthy household environment and lack of health services.

Basic causes are related to poverty, unequal distribution of resources at local, national
and international level. Health workers are best placed to deal with the immediate
causes of malnutrition, and these will be the focus of this chapter.


Impact of under-nutrition on child health.

Table2: Impact of under-nutrition on under-five mortality and morbidity
Condition Annual number of child
deaths
Proportionate
contribution to Disability
adjusted life-years
(DALY’s) for children
aged < 5 years
Stunting, severe wasting,
and intra-uterine growth
restriction
2.2 million 21%
Vitamin A and Zinc
deficiency
0.6 million 9%
Iron and iodine deficiency Few deaths 0.2%
Iron deficiency as risk of
maternal death
115,000 0.4%
Sub-optimal
breastfeeding (especially
non-exclusive
breastfeeding in first 6
months of life)
1.4million 10%

DALYS combine years of life lost due to premature death with years of life lived with
disability into an indicator that allows assessment of total loss of health from different
causes. One DALY is roughly one year of healthy life lost. The nutrition conditions that
are included in the analysis are protein energy deficiency, iron deficiency, vitamin A
deficiency and iodine deficiency. These estimates may under-estimate the impact of
nutrition on health and disease because under-nutrition has a synergistic effect with
many infectious conditions that lead to child death.

Table 2 is based on a global analysis that set to determine the impact of under-nutrition
on child mortality and disability with the latter measured as proportionate contribution of
the condition to the disability adjusted life-time years. This analysis based on
demographic data from countries of all regions of the world was that maternal and
under-five malnutrition is the underlying cause of death for 3.5million children annually,
35% of the burden of disease among children under five years of age and 11% of the
total DALY’s.






49
Low birth weight
Low birth weight contributes to increased mortality from asphyxia, and infections
(pneumonia, diarrhoea and sepsis) which account for 60% of all neonatal mortality.

Contribution of infectious disease to stunting and intra-uterine growth restriction
Infection increases nutrition requirements while at the same time it is associated with
reduced intake or even increased losses. Diarrhoea as model of the interaction of
infection and nutrition has been well studies and it has been shown that 1.05 (95% CI
1.03-1.07) increase odds of stunting at 24 months with every episode of diarrhoea.
Malaria in pregnancy increases risk of foetal death with greatest harm noted in
infections during late pregnancy.

PREVENTION OF NUTRITIONAL DISORDERS

Table 3 Interventions that Affect Maternal and Child Nutrition
Sufficient evidence for widespread
implementation
Evidence for implementation in
specific contexts
Maternal and birth outcomes
Iron folate supplementation Maternal supplements of balanced
energy and protein
Maternal supplements of multiple
micronutrients
Maternal iodine supplements
Maternal iodine through iodized salt Maternal deworming during pregnancy
Maternal calcium supplements Intermittent preventive therapy for
malaria
Intervention to reduce tobacco
consumption or indoor pollution
Insecticide treated bed nets
New born babies
Promotion of breastfeeding
to individuals or in group counseling)
Neonatal vitamin A supplementation
Delayed cord clamping
Infants and children
Promotion of breastfeeding individually
or in group counseling)
Conditional cash transfers
(with nutrition education)
Zinc supplementation
Zinc in management of diarrhea De-worming
Vitamin supplementation or fortification Iron fortification and supplementation
programs
Universal salt iodization Insecticide treated nets
Hand washing or hygiene intervention
Treatment of severe acute malnutrition

Interventions that affect mother and child nutrition can be categorized into interventions
that have sufficient evidence for universal implementation and those that are beneficial
in specific situations. The interventions are categorized into those that impact maternal
and birth outcomes, interventions for newborn babies and interventions for infants and
children. The interventions include general nutrition interventions, micronutrient
supplementation and disease control interventions. Up to 25% of the DALY’s can be



50
averted through comprehensive nutrition interventions. The four most effective
interventions are breastfeeding promotion, which would result in a 9.1% reduction in
mortality and 21.9% reduction in stunting followed by vitamin A and
zinc supplementation and balanced energy supplementation in that order as shown in
table 4 below

SPECIFIC NUTRITIONAL PROBLEMS

Maternal under nutrition
Maternal short stature is height < 145 cm while low body mass index is < 18.5Kg/M
2
.
To a large extent maternal short stature is a sequelae of stunting during childhood. Low
maternal body mass index is associated with intra-uterine growth restriction and low
birth weight. Adequate feeding throughout the girl and adult woman’s life is thus
important to prevent low birth weight.

Maternal under-nutrition has little effect on the volume or composition of breast milk
unless the mother is severely undernourished. But micronutrient content of breast milk
is dependent on the intake and nutritional status of the mother and therefore
micronutrient supplementation of the lactating woman is a strategy of ensuring
adequate supply to the baby.

Vitamin A deficiency
Vitamin A helps to maintain the integrity of cells on body surfaces and to form retinal
pigments and to destroy toxic products that cause tissue damage during infection.
Children with vitamin A deficiency are prone to respiratory infections and diarrhoeal
diseases. It is the commonest cause of blindness (xerophthalmia) in children. Vitamin A
deficiency is a public health problem affecting about 10 million children every year.

Vitamin A supplementation reduces childhood mortality for children suffering from
diarrhoea or measles infection. Currently WHO recommends that all children Vitamin A
supplementation, 100,000IU at 6 months of life and then 200,000 IU every 6 months
thereafter until the child is 5 years old.

A child with any sign of xerophthalmia, measles, diarrhoea and severe malnutrition
should receive oral vitamin A on day 1, day 2 and repeat after 2-4 weeks. Children with
corneal lesions should be treated immediately or referred urgently as an hour’s delay in
treatment can lead to loss of sight.
The doses are:
Infant <6 months old: 50,000 IU
Infant 6-11 months old: 100,000 IU
Child 1-5 year old: 200,000 IU

Zinc deficiency
A trace element that is essential for growth and development of infants/children. The
main source of dietary zinc is meat, eggs, nuts, seeds and grains.
Zinc deficiency alters taste and smell; increases risk of diarrhoea, pneumonia and
malaria; growth retardation; and delayed wound healing. Zinc supplementation is



51
recommended in treating diarrhoea malnutrition and in chronic liver disease. The dose
of zinc during treatment is 2-3mg/kg/day

Table 4: Indirect indicators of Zinc deficiency
Country category of Zinc deficiency Characteristics
High risk of Zinc deficiency Prevalence of stunting of > 20%
Estimated prevalence of inadequate
zinc intake of > 25%
Medium risk of Zinc deficiency Prevalence of stunting of 10%- 20%
Estimated prevalence of inadequate
zinc intake of 10%-25%
Low risk of Zinc deficiency Prevalence of stunting < 10%
Estimated prevalence of inadequate
zinc intake of > 25%

Using the above criteria all the countries in sub Sahara Africa other than Zimbabwe,
Botswana and republic of South Africa are classified as having a high risk of Zinc
deficiency.

Iron deficiency
Up to 40% of pregnant women and children worldwide have anaemia, 60% of which is
nutrition related. In children peak of iron deficiency is 18 months.
The main cause of iron deficiency anaemia is lack of animal source foods (fish, meat, or
poultry) in the diet.
Iron deficiency increase risk of mother’s death and affects children’s cognitive function.
The lower the haemoglobin, the higher the consequences of these conditions. There is
some evidence that iron supplementation has some benefit on IQ. Iron supplementation
is not recommended during an attack of malaria endemic regions where increased child
mortality was reported following iron supplementation.

Iodine deficiency
Iodine deficiency manifests with enlarged goitre, congenital hypothyroidism and
developmental disability. Traditionally these conditions have been used to assess the
prevalence of iodine deficiency. Newer methods include concentration of iodine in
urine.
Iodine deficiency during pregnancy impairs motor and mental development of the foetus
and increases the risk of miscarriage and foetal growth restriction. The best prevention
is use of iodized salt.

Folic acid, B vitamins and other micronutrient deficiencies

Calcium deficiency is the leading cause of rickets in sub Sahara Africa. Lack of
exposure to sunlight and the relatively infrequent use of vitamin D supplements leads to
development of rickets. In-utero vitamin D deficiency can be associated with poor
growth and bone mineralization which is further aggravated by low concentrations of
vitamin D in Breast milk.




52
Folate deficiency causes megaloblastic anaemia. And in pregnancy neural tube
defects other defects and possibly increased prevalence of pre-eclampsia. Good
sources of folic acid are fruits, leafy green vegetables, and liver. Treatment of
deficiency-folic acid comes in a tablet, usually taken once a day

Women with B12 deficiency have such low levels in milk that babies start manifesting
symptoms that include failure to thrive, stunting, poor neuro-cognitive development or
even global developmental delay. All these delays are irreversible.

MANAGEMENT OF ACUTE SEVERE MALNUTRTION

Definition:
Severe acute malnutrition is defined as the presence of severe wasting (<70%
weight-for-height or <-3SD) and/or oedema. There is severe wasting of the
shoulders, arms, buttocks and thighs with visible rib outlines. Other features include:
Irritability, misery and apathy, pale sparse hair, skin changes, oedema and poor
appetite.

NUTRITIONAL ASSESSMENT OF THE CHILD

ASK
Ask mother/caregiver (or check the medical records). Has the child lost weight
during the past month? Does the child have conditions that put them at nutrition risk
like HIV infection, a cough for more than 21 days, active TB on treatment, diarrhoea for
more than 14 days, other chronic OI or malignancy
LOOK and FEEL
Look for signs of severe visible wasting- loss of muscle bulk and sagging skin/ buttocks.
Check for presence of oedema of both feet (and sacrum).
Check the weight and height. Is the weight-for-height less than -3 z-scores? Is the child
very low weight (weight for age less than -3 z-scores)? Is the child underweight
(weight for age less than -2 z-scores)?
Check the MUAC
Table 5: Cut-off points for MUAC for children of different ages
Age MUAC cut off point for
under-weight
MUAC cut off point for
severe malnutrition
6months-12 months <12.0cms <11.0cms
1 year-5 years <13.0cms <11.0cms
6 year-9years <14.5cms <13.5cms
10years-14years <18.5cms <16.0cms

Look at the shape of the growth curve
Has the child lost weight since the last visit? (Confirm current weight by repeating
measurement). Is the child’s growth curve flattening? Is the child gaining weight?






53
CLASSIFY THE NUTRITIONAL STATUS
Table 6: Classification of nutrition status
Acute Severe
Malnutrition
Poor weight gain Growing well Has conditions
with increased
nutrition needs
Signs of severe
visible wasting, or
Oedema present
in both feet, or
Weight-for-height
less than
-3 z-scores below
median WHO
reference value,
or
MUAC less than:
- 110mm in
infants 6mo-
12mo
- 110mm in
children 1yr-
5yrs
- 135mm in
children 6yrs-
9yrs
- 160mm in
children 10yrs-
14yrs

Reported weight
loss, or
Very low weight
(weight for age
less than -3 z-
scores), or
Underweight
(weight for age
less than -2 z-
scores), or
Confirmed weight
loss (>5%) since
the last visit, or
Growth curve
flattening, or
MUAC less than:
- 120mm in
infants 6mo-
12mo
- 130mm in
children 1yr-
5yrs
- 145mm in
children 6yrs-
9yrs
- 185mm in
children 10yrs-
14yrs

Child is gaining
weight

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


TREAT MALNUTRITION
Care givers of children who are growing well should be encouraged on how to continue
to support their children nutritionally.

Children who are growing well but have a chronic illness like HIV require 10% more
energy calories on top of their usual requirements.

Children who are growing poorly or have a condition that increases nutrition
requirements such as TB require 30-40% increase in the energy calories.

All children classified as severe malnutrition require therapeutic feeding.



54
Management of Acute severe Malnutrition (the ‘10 Steps’)
(Adapted from WHO guidelines for treatment of severely malnourished children)

Remember: Rehydration with intravenous fluids can increase mortality, as can
manipulation of abnormal blood chemistry. Aggressive attempts to promote rapid weight
gain from the start of treatment are also dangerous as is giving a high protein diet for
children with kwashiorkor. Prescribing diuretics to get rid of oedema can be fatal. Iron
supplementation to treat anaemia increases deaths in the initial phase of treatment.

There are ten essential steps for managing acute severe malnutrition
There is an initial stabilization phase where the acute medical conditions are
managed; and a longer rehabilitation phase. Note that treatment procedures are
similar for marasmus and kwashiorkor.

A: STABILIZATION PHASE

STEP 1. TREAT/PREVENT HYPOGLYCAEMIA
All severely malnourished children are at risk of hypoglycaemia and should be given a
feed or 10% dextrose or sucrose on admission. If blood glucose cannot be measured,
assume all severely malnourished children are hypoglycaemic.
To treat/prevent hypoglycaemia by giving the first feed of F-75. If the first feed is not
quickly available, give 50ml of 10% glucose or sucrose solution (1 rounded teaspoon of
sugar in 3.5 tablespoons water), orally or by nasogastric (NG) tube, followed by the first
feed as soon as possible. The child should then continue with 2-3 hourly feeds of F-75
day and night at least for the first day. Continue monitoring closely for hypoglycaemia,
and repeat the 10% glucose or sugar solution every 30 minutes until stable.

STEP 2. TREAT/PREVENT HYPOTHERMIA
Check for hypothermia axillary temperature <35
o
C If present warm with blankets, a
heater in the room or skin-to-skin contact with mother. Check temperature 2 hourly until
it rises to >36.5
o
C. The child should be kept covered at all times, especially at night.
In order to treat and prevent hypothermia, the child should be fed immediately and
then 2 hourly.

STEP 3. TREAT/PREVENT DEHYDRATION
Dehydration is difficult to diagnose in malnutrition. It is either over or under diagnosed.
Low blood volume can coexist with oedema. All severely malnourished children with
watery diarrhoea should be assumed to have some dehydration.
Do not use the IV route for rehydration except in cases of shock. The standard WHO-
ORS solution contains too much sodium and too little potassium for severely
malnourished children. Instead use special Rehydration Solution for Malnutrition
(ReSoMal) Give ReSoMal (orally or by nasogastric tube) 5 ml/kg every 30 minutes for 2
hours, and then continue with 5-10 ml/kg/h for next 4-10 hours. Replace the ReSoMal
doses at 4, 6, 8 and 10 hours with F-75 if it still necessary to continue rehydration at
these times. Once rehydrated initiate/continue feeding with starter F-75.

The progress is monitored half-hourly for two hours, then hourly for the next 6-12 hours,
recording pulse rate, respiratory rate, urine frequency, stool/vomit frequency. During re-



55
hydration, rapid respiration and pulse rates should slow down and the child should
begin to pass urine. Continuing rapid breathing and pulse during re-hydration suggest
coexisting infection or over-hydration. If these signs occur, stop ReSoMal immediately
and reassess after 1 hour.
To prevent dehydration in a severely malnourished child with continuing watery
diarrhoea:
• If the child is breastfed, continue breastfeeding.
• Continue feeding with starter F-75.
• Give ReSoMal between feeds to replace stool losses. As a guide give 50-100 ml after
each watery stool.

STEP 4. CORRECT ELECTROLYTE IMBALANCE
All severely malnourished children have deficiencies of potassium and magnesium
which may take at least two weeks to correct. Oedema is partly due to these
imbalances. Do NOT treat oedema with a diuretic. Excess body sodium exists even
though plasma sodium may be low. Giving high sodium loads could kill the child.
Prepare food without adding salt. If available give the multi-mineral mix if not give extra
potassium (3-4 mmol/kg/day) and magnesium (0.4-0.6 mmol/kg/day).

STEP 5. TREAT/PREVENT INFECTION
Assume infection even in the absence of clinical signs and start antibiotics immediately
on arrival in hospital.
Give a broad-spectrum antibiotic(s) {penicillin/amoxicillin and gentamicin} and
metronidazole; if no improvement after 48 hours add chloramphenicol; and measles
vaccine if child is > 6 months and not immunized (delay if the child is in shock). Treat
for malaria in high endemic zones or if the child has a positive blood film for malaria
parasites. Mebendazole 100 mg orally twice a day for 3 days if there is evidence of
worm infestation. In countries where infestation is very prevalent, give mebendazole to
all malnourished children after day 7 of admission. If anorexia persists after 5 days of
antibiotic treatment, complete a full 10-day course. If anorexia still persists, reassess the
child fully, checking for infections e.g. TB, HIV and potentially resistant organisms, and
ensure that vitamin and mineral supplements have been correctly given.

STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES
Vitamin A orally on day 1, Repeat on day2 & 14 if there are eye signs.
Give daily for at least 2 weeks:
- A multivitamin supplement,
- Folic acid (give 5 mg on Day 1, then 1 mg/day),
- Zinc (2 mg/kg/day),
- Copper (0.3 mg/kg/day) and
Iron (3 mg/kg/day but only when gaining weight).
A combined electrolyte/mineral/vitamin mix for severe malnutrition is available
commercially. This can replace the electrolyte/mineral solution and multivitamin and
folic acid supplements mentioned in steps 4 and 6, but still give the large single dose of
vitamin A and folic acid on Day 1, and iron daily after weight gain has started.






56
B: STABILIZATION PHASE

STEP 7. START CAUTIOUS FEEDING

In the stabilization phase a cautious approach is required because of the child’s fragile
physiological state. Feeding should be started as soon as possible after admission and
should be designed to provide just sufficient energy and protein to maintain basic
physiological processes.

The essential features of feeding in the stabilization phase are:
• Small, frequent feeds of low osmolarity and low lactose
• Oral or nasogastric (NG) feeds (never parenteral preparations)
• Energy: 100 kcal/kg/day
• Protein: 1-1.5 g /kg/day
• Fluid: 130 ml/kg/day (100 ml/kg/d if the child has severe oedema)
• If the child is breastfed, encourage to continue breastfeeding but give the prescribed
amounts of starter formula to make sure the child’s needs are met.
Milk-based formulas such as starter F-75 containing 75 kcal/100 ml and 0.9 g
protein/100 ml will be satisfactory for most children. Feed by tube if needed. A
recommended schedule in which volume is gradually increased, and feeding frequency
gradually decreased is:
Days Frequency Vol/kg/feed Vol/kg/d
1-2 2-hourly 11 ml 130 ml
3-5 3-hourly 16 ml 130 ml
6-7+ 4-hourly 22 ml 130 ml

For children with a good appetite and no oedema, this schedule can be completed in 2-
3 days. Do not exceed 100 kcal/kg/day in this phase. Closely monitor all the amounts of
feeds offered and left over, vomiting, stool frequency and consistency and daily body
weight

STEP 8. ACHIEVE CATCH-UP GROWTH
Once appetite has returned and oedema is resolving, a vigorous approach to feeding is
required to achieve very high intakes and rapid weight gain of >10 g gain/kg/day.
Replace starter F-75 with the same amount of catch-up formula F-100 for 48 hours
then,
Increase volume of each successive feed by 10 ml until some feed remains uneaten.
Modified porridges or modified family foods can be used provided they have
comparable energy and protein concentrations. The goal is to provide 150-220
kcal/kg/day of energy and protein 4-6 g/kg/day. However breast milk does not have
sufficient energy and protein to support rapid catch-up growth, so give F-100 as
indicated. Weigh the child each morning before feeding and plot the weight. Progress
after the transition is monitored by assessing the rate of weight gain every 3 days as
g/kg/day. If weight gain is poor (<5 g/kg/d), child requires full reassessment. If sign of
heart failure (rapid pulse and fast breathing) occur the feeds should be increased
slowly.





57
STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT
In severe malnutrition there is delayed mental and behavioural development.
Provide tender loving care, a cheerful, stimulating environment, structured play therapy
15-30 min/day and physical activity as soon as the child is well enough. The mother or
the primary care-giver should be involved in the care process (e.g. comforting, feeding,
bathing, play)

STEP 10. PREPARE FOR FOLLOW-UP AFTER RECOVERY
A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have
sufficiently recovered and ready to continue at home. The child is still likely to have a
low weight-for-age because of stunting.
Throughout the hospital stay mother/care- giver should have nutritional counseling on
how to prepare and feed energy and nutrient dense meals at home using the food
readily available in the household. Good sensory stimulation should be continued at
home. Ensure adequate immunization before discharge and give clear instructions for
follow up care.

HOME MANAGEMENT OF ACUTE SEVERE MALNUTRITION
Children with severe acute malnutrition, who have a good appetite and no obvious
complications are good candidates for community rehabilitation. This is done with ready
to use therapeutic food (RUTF). Community feeding saves money and possible
exposure to new infections in the hospital

Ready to use food (RUTF) in management of acute severe malnutrition
RUTF is an energy dense paste that has nutrients in the same proportion as the WHO
F100 formulation. It is made by replacing dry skimmed milk (DSM) in the F100 with
peanut butter paste. This gives an energy rich paste that can be eaten directly by the
child without addition of water and thus reducing the risk of bacterial contamination.
RTUF is associated with greater weight gain than F100 or corn-soy blends used for
therapeutic feeding. RTUF does not rely on mother’s cooking skills to prepare. Weekly
or fortnightly follow up (weight and MUAC) until the child recovers should be planned.

RTUF can be used as a therapeutic feed, when it provides all the nutrients the child
requires or as supplement for some of the child’s nutrients while the rest is provided by
the home diet. This is most ideal in the recovery phase from malnutrition

NUTRITIONAL MANAGEMENT OF CHILDREN WITH CHRONIC DISEASE

Children with chronic disease such as HIV have increased nutrient requirements. At
every point of contact the child should be assessed to determine whether they have:

 Severe malnutrition
 Gaining weight poorly
 Growing well
 Having conditions that increase energy requirements such as infection, TB,

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



58
HIV infected children who are growing poorly or have conditions that increase energy
requirements such as chronic cough, diarrhoea, or TB require 30-40% more calories in
their diet. The table below gives examples of how this can be achieved using a food
based approach. The learner should check with the local Ministry of Health on other
foods that can be used to meet these additional energy requirements.

Table 8: Examples of food portions that can be used to increase energy content of diet
for children of different ages.
HIV infected child who is
growing well
HIV infected child who is
growing poorly or has
conditions increased
nutrient requirements
Additional nutritional
requirement on top of
normal requirements
10% increased energy
requirement
30-40% increased energy
requirement
6-11 months 1-2 spoonfuls of fat/oil or 1-
2 spoonfuls sugar added to
porridge
2 tsp oil & 1-2 tsp sugar to
porridge. Aim to add 3
times daily
12-23 months 1-2 spoonfuls of fat/oil or 1-
2 spoonfuls sugar added to
porridge
extra cup of full cream milk
or cheese/peanut butter
sandwich (1 slice)
2-5years extra cup of full cream milk
/ fermented milk in addition
to the normal diet
extra cup of enriched milk
or cheese/peanut butter
sandwich (4 slices)
6-11year extra cup of full cream milk
/ fermented milk in addition
to the normal diet
extra cup of enriched milk
or cheese/peanut butter
sandwich (6 slices
12-14year extra cup of fruit yoghurt or
cheese/peanut butter
sandwich in addition to the
normal diet
3 cheese/peanut butter/egg
sandwiches (6 slices)
If the food items in the table are not available explore with the care giver what can be
used as alternatives.

OBESITY
Obesity is an emerging concept and the prevalence is on the increase all over the
world. It results from an inappropriate high calorie intake with low physical activity.
Management focuses on encouraging well balanced healthy meals and increasing
physical activity.
Interventions for obesity include;
 Promoting an active lifestyle and limit television viewing
 Limiting high energy-dense nutrient poor foods salty snacks, ice cream fried foods,
cookies and sweetened beverages and emphasize on fruits and vegetables
 Set regular meal times, preferably eating as a group to promote social interaction
and role model food-related behaviour.
The lifestyle changes should involve the whole family since it’s a lifelong programme,
needing a lot of support from all concerned bearing in mind a better body image and self



59
esteem being inculcated, cardiovascular diseases and diabetes risks reduced
remarkably.
REFERENCE

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

2. Bhutta Z, Ahmed T, Black RE, et. al. What works? Interventions for maternal
and child under-nutrition and survival. Lancet 2008; 371:417-40.

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

4. World Health Organization: Guidelines for an Integrated Approach to the
Nutritional care of HIV-infected children (6 months – 14 years) Final Draft – 6
th

February 2008

5. www.mypyramid.gov




60
CHAPTER 5

EARLY CHILDHOOD DEVELOPMENT

Ruth Nduati

INTRODUCTION
Child growth and development go hand in hand. While growth is a result of increase in
overall size due to increasing number of or enlarging body cells or both, development is
the acquisition of increasingly complex skills for individuals’ adaptation and survival.
Development is a continuous process from conception to adulthood. Indeed the
process of birth is only an event during development. It depends on the maturation of
the nervous system. It is cephalo-caudal in progression and although the sequence is
the same in al normal children, the rate differs. The initial phase of development
involves massive body responses which become specific in later life (for example a six
month old child trying to reach an object with the whole body movement while at the
two years of age the same child simply stretches the arm to reach the object. Due to its
sophisticated and continuous nature, development in a child is amenable to influences
both inherent in the body and external.

It is estimated that more than 200million under 5 children in developing countries do not
achieve their full development potential. In developing country settings there are four
well documented risk factors for poor development: (i) stunting (ii) iodine deficiency (iii)
iron deficiency, and (iv) sub-optimal cognitive and socio-emotional stimulation. In
addition there are four other environmental factors that pose a risk to the development
of the child which include maternal depression, exposure to violence, environmental
contamination, and infections such as malaria and HIV. These factors interfere with a
child’s development and contribute to a trajectory of poor health, lack of readiness for
school, poor academic performance, inadequate preparedness for economic
opportunities and perpetuation of the general cycle of poverty. Primary care can create
an environment that is conclusive to the child’s development. In this chapter, the
student will learn about child development and the factors that influence it.

Objective
At the end of this chapter the learner should be able to;
Outline factors that influence development of the infant and child.
List the developmental domains
Describe the developmental stages of children from birth to age 5 years
Carry out a screening development assessment
Recognize deviations from normal development
Relate developmental to infant feeding practices.
List dangers faced by the child because of stage of development
Outline strategies for promoting child development.

Learning activities
Visit a well child clinic and assess developmental stage of babies aged 1-2 months, 2-6
months and 6months to a year.



61
Visit the paediatric ward and asses the development of a child admitted with severe
malnutrition.

Spectrum of growth and development
Growth and development encompasses somatic growth where there is formation of
tissues and enlargement of the head, trunk and limbs. There is progressive increase in
ability to control larger and small muscles. There is also development of social
relatedness, thought, language and emergence of personality. Development on the
other hand is the process of adaptation of the child to the environment. The
environment in which the child is growing needs to provide for their physical and
psychological needs. Physical needs include food, good health, activity and rest,
warmth, clothing, shelter, good vision and hearing. The psychological needs include
security; personal identity, self respect and independence; affection and care; play;
opportunity to learn from experience; and role models. Failure to provide for these
needs may result in delayed or abnormal development. Early childhood development
predicts subsequent school performance.
Factors that influence growth and development

Factors that influence a child’s development can be classified as;

(i) Biological influences

Biological clock
There is a set time when certain skills are achieved, for example children walk at one to
one and a half years all over the world

Genetic endowment
Parental advance age, especially maternal increased age can lead to chromosomal
abnormalities in the conceived foetus. This subsequently causes organ abnormalities
including abnormalities in the central nervous system. A foetus that grows to delivery is
thus ill suited for normal development. Couple counseling, antenatal genetic screening
and therapeutic abortions may be of help in such cases.

In-utero exposure to teratogens such as mumps virus, alcohol, drugs of abuse or
therapeutic agents
Mothers infected with rubella, HIV, toxoplasmosis, cytomegalovirus, severe extra
pulmonary tuberculosis may infect her developing foetus with the result of damage to
the nervous system amongst other foetal organs. Careful antenatal screening,
vaccination and treatment can prevent some of these.

Poorly managed maternal diabetes mellitus, hypertension, heart disease, poor nutrition
etc can all lead to poor foetal and later, poor child development.

Some medicines given to the mother early in pregnancy may lead to developmental
abnormalities of the foetus – which become life long. These include radiation (e.g. X-
ray) and cancer drugs.




62
Nutritional deficiencies in the mother during pregnancy have negative impact on foetal
development. For example, folic deficiency may lead to abnormal neurodevelopment of
the foetus. Folic acid supplementation is therefore important during pregnancy.

Perinatal Asphyxia
Perinatal injuries and birth asphyxia to the baby remain a significant cause of morbidity
and mortality in children in the developing countries. The brain is particularly vulnerable
and this tends to lead to subsequent abnormal development in the child. Proper labour
monitoring, conduction of delivery and newborn resuscitation can reduce this problem..

Postpartum illness – meningitis, chronic illness
Severe infections in the child, such as meningitis, can cause brain injury with
subsequent abnormal development. Some of these infections are adequately
prevented through immunization.

Malnutrition – stunting, iodine and iron deficiency
Proper nutrition is crucial to normal child development. This is discussed in details in
the relevant chapters.

Exposure to hazardous materials/agents – heavy metals – lead, mercury
Some drugs and poisons cause long lasting damage to children, especially if they are
not managed well. These include lead poisoning and mercury poisoning. The net effect
is impaired development. Prevention of poisoning and appropriate management of
affected children is therefore this important.

Accidents and injuries
Due to their explorative nature, children are always exposed to accidents and injury.
Where these involve the vital systems (like brain), there may be impaired subsequent
development. This is addressed in detail the relevant chapter.

(ii) Environment and social exposure
The environment contributes to child development by providing physical needs such as
food, shelter, good health, functioning senses and stability. The environment also
provides for the psychosocial needs of the child. The child needs appropriate
stimulation to develop well. Stimulation is provided for through:
Play
Affection and care
Role models
Opportunity to learn from experience
Security
Personal identity, self-respect and independence

(iii) Child’s temperament may also affect their development
Several parameters for assessing temperament have been described
Activity level - Amount of gross motor movement
Rythmicity - how regular is the biological clock
Approach and withdrawal adaptability - typical response to a new stimulus, or how long
it takes to adapt to novel stimuli



63
Threshold of responsiveness - how intense should a stimulus be to evoke a response
Intensity of reaction
Quality of mood -usual disposition always happy, always unhappy, always hungry in
class
Attention span and persistence -how long does the child pay attention and stick to a
difficult task
There is value in understanding a child’s temperament and health workers should help
parents understand and accept the characteristics of their children. Behavioral and
emotional problems tend to occur when the temperamental characteristics of the child
and parents conflict. For example, active children maybe a problem for low-key
parents, while slow to warm up children may be pressured by outgoing parents. Parents
who live highly structured lives may fare poorly with children whose biological clocks
occur less regularly.

(iv) Psychological attachment
The first year is a time of developing ‘basic trust’ based on mother’s consistent
responsiveness to the child’s needs. The attachment reflex is the biologically
determined tendency of a young child to seek proximity with parents during periods of
stress. Children who are securely attached are able to re-establish a sense of well
being after a stressful event such as a physical examination or immunization. Insecure
attachment may signal dysfunctional attachment and dysfunctional development and
behaviour later on. At all stages development and across different lines of
development is fostered by adult caregivers who observe a child’s verbal and non-
verbal cues and respond accordingly. Responses to non-verbal gestures create the
ground work for language and social development. At all stage development fostered
by presenting the child with tasks that are just a little harder than what has been
mastered and optimal tasks fall in the ‘zone of proximal development

Social factors
Factors beyond the mother-infant dyad contribute to a higher or lower level of stress
and which impact on the mother-infant relationship. If the mother has an abusive
spouse she may become depressed and is therefore unable to respond appropriately to
the child. Families are complex sub-systems with defined boundaries, subsystems,
roles and rules of interactions. Family with rigidly defined parental systems may deny
children an opportunity to participate in decision-making and thereby exacerbate
rebelliousness. Change in family structure, or individual behaviour results in role
changes until new equilibriums are found for example sick parent who becomes
dependant, or loss of parent. Wider societal issues also influence lives of families.
Increasing urban poverty may radically change the roles of different family members
and in the process adversely affecting child development. The child’s development
ultimately influenced by the interaction of biology and social interactions.

Case study:
Pre-term baby may cry little and sleep long periods of time. A depressed mother
welcomes this as good behaviour setting-up a cycle that leads to poor nutrition, slow
growth and failure to thrive. The child’s failure to thrive may reinforce the parents’
sense of failure. Later impulsivity, inattention and under-nutrition may interact with



64
mother’s depression leading to referral for aggressive behaviour. The cause of the
aggression is sum total of prematurity, under-nutrition and mother’s depression.

Risk factors versus resilience
Resilience is the description that is given to children who make it despite great odds.
Children who are temperamentally persistent or athletic demonstrate greater resilience.
Socially having one trusted adult often the parent, grandparent or teacher with whom
the child has a close relationship helps to nurture resilience. In sub Sahara Africa many
children are living in difficult circumstances. Resilient children have better ability to
survive. Health workers need to harness and support structures that strengthen
children’s resilience. Evaluation of a child should include not only the risk factors but
also the protective strengths.

STAGES OF DEVELOPMENT
Developmental domains
Each of these domains has a line of development or sequences of changes until
maximal skills are achieved.
Gross motor
Fine motor
Social
Emotional
Language
Cognition
Other skills that are important in the older child and which profoundly affecting learning
are the ability to pay attention and to concentrate.

Development;
Has a constant pattern
Begins in utero
Should be considered longitudinally relating what has happened to what lies ahead
Varies in rate between children
There is inter-relatedness in the acquisition of the different skills with deficiencies in one
area affecting development of another area. For example hearing deficits have
profound effect on development of language, as well as socio and behavioral skills.

0-2 months
The first year is a period of rapid physical growth and maturation and acquisition of
numerous competencies. Growth takes place in spurts that qualitatively change the
child’s behaviour

Behavioural goals
In the first 2 months of life the main behavioural goals are to establish;
effective feeding,
a predictive pattern of sleeping and waking and
social interaction that becomes the basis for future social and cognitive development.






65
Physical growth and Motor Development
In the 1st week there is a 10% drop in weight which is regained or exceeded by end of
second week. During this period the average weight gain 30g/day. The infant’s
movements in the first 2 months are largely uncontrolled except for the eye gaze, head
turning and sucking. Smiling occurs involuntarily. Babies cry in response to stimuli
such as wet diaper, hunger, and over-heating. Crying peaks at 6 weeks of life with at
least 3hrs/day, and then declines to 1hr/day. Neurological development contributes to
the longer blocks of sleeping time. Learning also contributes to sleeping habits with
babies shifting to night time breastfeeding if the mother is away at work during the day.

Cognitive development
Babies receive visual, tactile, olfactory and auditory stimulus. Infants habituate to the
familiar and pay less and less attention to a stimulus that is presented repeatedly. In
the first 2 months babies can differentiate among similar patterns and colours and
consonants. They respond to facial expressions even when they appear on different
faces. They are also able to match abstract properties of stimuli, for instance they can
tell difference between sound from movement of lips or from a video-tape
Emotional development
The key task in emotional development is to develop basic trust. Key to this goal is
consistent availability of a trusted adult. Babies who are consistently picked and held in
response to distress cry less at one year and have less aggressive behaviour at 2
years. Feeding plays a key role in emotional development. On-demand fed babies link
distress with arrival of mother and relief from distress. Babies fed on fixed schedule
usually adapt. Babies with unstable biologic rhythms and who are fed on a fixed
schedule experience periods of un-relived hunger or unwanted feedings. Similarly
babies fed at parents convenience with complete disregard of baby’s need do not
experience feeding as the favourable reduction of tension. Babies who have a
mismatch between feeding and hunger have increased physiologic instability
manifesting as diarrhoea, spitting, poor weight gain) as well as later behavioural
problems

Success in establishing feeding and sleep cycles increases the parents’ sense of
efficacy independent of child’s temperament. Normally anxiety and ambivalence
experienced by the mother/parents in the first few days after the birth of their baby settle
down as baby develops regular rhythms. Mothers with post-partum depression or blues
may have a harder time making the adjustment and need specific support.

2-6 months
During the period of 2-6 months the voluntary (social) smile and increased eye-to-eye
contact emerges. Parents experience a heightened sense of being loved. At 3-4
months weight gain slows down to 20g/day.

Motor and Physical development
Early reflexes that limit movement recede. There is loss of asymmetrical tonic neck
reflex which means that infants can roll over and also begin to examine objects in the
mid-line and manipulate them with both hands. Waning of grasp reflexes means that
the child can hold an object voluntarily and also let go. A novel object may elicit
purposeful but inefficient reaching. Babies have increased control of truncal flexion



66
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



67
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



68
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



69
demonstrate flexibility in problem solving, and for instance may use a stick to reach a
toy that is out of reach. Symbolic play is now not tied to the toddlers’ body, for example
a toy can be fed. Cognitive changes have significant effect on emotional and linguistic
development.

Emotional development
There is increased clinginess as the child becomes more aware of separation.
Separation at bed-time difficult and many children use special blanket or toy as a
transition object, which maybe representing the absent parent. Transition objects
remain until symbolic language develops. Self conscious awareness develops and an
example is when looking at a mirror the child will reach for their own face and not at the
mirror. The child will recognize that toys are broken and may ask parents to fix them.
When tempted to touch a forbidden object they themselves say no- no-no showing that
they are internalizing standards of behaviour.

Linguistic development
Children continue to develop symbolic language. The vocabulary increases from 10-15
words at 18 months to > 100 words at 2 years as children realize that words stand for
things. Once they have 50 words they are able to combine words to make simple
sentences. At 2 years able to follow a two step command e.g. ‘put on your shoes and
then kick the ball’. Emergence of verbal language skills marks the end of the
sensorimotor period. The child learns to use symbols to express ideas and solve
problems and this diminishes the need for cognition based on sensation and motor
manipulation.

Physical limits on child’s exploration become limited with the child’s increased mobility.
For example the child is able to climb out of his cot. There is now increased need for
behaviour control that is based on language. Children with delayed language
acquisition have greater behavioural problems. Language development is facilitated
when parents and other care givers use clear, simple sentences, ask questions and
respond to children’s incomplete sentence and gestures with the correct words.
Regular looking at picture books with a parent provides ideal setting for language
development.

Age 2-5 years

Motor Development
There is reduced somatic and brain growth and therefore reduced food intake and
appetite. During the period 2-5 years children gain 2Kg in body weight and 7cm in
height/year. The child’s prominent abdomen flattens. Physical energy peaks and sleep
requirement declines to 11-13hrs/24 hours. Visual acuity 20/30 at 3 years and 20/20 by
4 years.

All 20 primary teeth erupted by 3 years. Most children walk with a mature gait and run
steadily by 3 years. Acquisition of other skills such as throwing, catching, kicking balls,
riding on bicycle, climbing play-ground structures varies widely. Intensity and
cautiousness during motor activity are influenced by child’s temperament. Energetic co-
ordinated children thrive in an environment that fosters physical competition. Lower



70
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.



71
Gross motor
Vision and fine motor
Hearing, speech and language
Socio-emotional and behavioural
Cognitive development is assessed on its own in the older child.

Table 1: SUMMARY OF FIELDS OF DEVELOPMENT

OVERVIEW OF DEVELOPMENTAL
STAGES
ACQUIRED SKILL
THAT IS
MONITORED
UPPER LIMIT OF
NORMAL
ACQUISITION OF
SKILLS
GROSS MOTOR DEVELOPMENT
Acquisition of tone and head control Head control 4 months
Primitive reflexes disappear
Sitting Sits unsupported 9 months
Standing, walking running Stands
independently
12 months
Hopping, jumping, pedaling Walks independently 18 months

VISION AND FINE MOTOR
Visual alertness, fixing and following Fixes and follows
visually
3 months
Grasp reflex, hand regard Reaches for objects 6 months
Voluntary grasping, pincer grip, pointer Transfers 8 months
Handles objects with both hands,
transfers from hand to hand
Pincer grip 12 months
Writing, cutting, dressing

HEARING, SPEECH AND LANGUAGE
Sound recognition, vocalization Polysyllabic babble 7 months
Babbling Consonant babble 10 months
Single words, understands simple
requests
Saying 6 words with
meaning
18 months
Joining words, phrases Joining words 2 years
Simple and complex conversations 3 word sentences 2.5 years

SOCIAL, EMOTIONAL AND
BEHAVIORAL

Smiling, socially responsive Smiles 8 weeks
Separation anxiety Fears strangers 10 months
Self help skills. Feeding, dressing,
toileting
Feeds self with a
spoon
18 months
Peer group relationships
Symbolic play Symbolic play 2-2.5 years
Socio/communication behavior Interactive play 3-3.5 years




72
Median age of acquiring a milestone is the age at which half of the children acquire the
skills, while the limit ages are usually 2 standard deviation above the median. The limit
ages for different development milestones are shown on table 1. These ages are a
guide to when the child’s development is normal and when an assessment is required to
determine the cause of delay in development. Adjustment for gestational age should
be made in the first two years of life during developmental assessment.

STRATEGIES FOR PROMOTING CHILD DEVLOPMENT

Conceptual frame work
Promotion of Early childhood development includes deliberate action to stimulate and
promote child development, prevents risks and ameliorates the negative effects of
various risks. Poverty is both a biological and psychosocial risk that affects
development and function of the central nervous system. In turn this may affect all
spheres of development namely sensory-motor, socio-emotional and cognition and
language. These in turn affect academic performance, economic performance and
worse than this, there is intergeneration transmission as cycle of poverty is perpetuated.


Source: Engle et al. Lancet 2007;369:229-242

Improving food intake and reducing stunting
Improving the diets of pregnant women, infants and toddlers reduces stunting. Food
supplements among 2-3year olds improves cognition well beyond that age. A long
standing study in Guatamela that provided nutrition supplements to children aged less
than 3 years, demonstrated benefits in schooling, reading and intelligence tests by
participants when they were assessed at the age of 25-42 years.

Reducing iodine and iron deficiency
There is conclusive evidence that reducing iodine and iron deficiency is associated with
improved cognition and behaviour. Use of iodinated salt is an effective way of proving
iodine at household level. One of the millennium development goals is universal
coverage is defined as 69% of all households use iodized salt. Globally this goal has



73
been achieve in Africa. Health workers need to constantly encourage the public to use
iodinated salt.

Iron deficiency anaemia impedes child development and the detrimental effect in
toddlers and infants is not readily reversed with supplements. Supplementation of
deficient children has shown positive effect on motor, socio-emotional and language
development.
Some of the strategies for improving iron security include use of micro-capsulated iron
with vitamin C, growing of iron rich foods, and removing phytates from plants at the
point of food production in order to reduce inhibition of iron absorption. Iron
supplementation of replete children has been shown to be associated with slowing
down of linear growth and increased hospitalization and death in endemic areas.

Stimulation combined with health promotion
Stimulation occurs through responsive and increasing complex developmentally
appropriate interactions between care-givers and children that enhance the child’s
development. Both cognitive and socio-emotional skills provide the basis of later
academic and employment performance. Early stimulation especially in pre-term babies
enhances neurocognition. Inadequate stimulation and interaction interferes with the
child’s development by affecting neural circuitry. Without interventions, changes in the
first 2 years maybe un-recoverable. Observations from developed country settings
show that children exposed to quality early childhood development programs have
better school performance. Higher verbal and mathematical skills, higher school
completion rates, better employment, better health outcomes, and less dependency on
welfare. The highest benefits are accrued by disadvantaged children including those
that are stunted, younger children compared to older ones, and longer exposure. The
quality of the programs matters with child initiated activities, smaller groups, high staff-
child ratio, and trained teachers having better outcomes. The process by which early
child development services are provided matters. The warmth of the caregiver,
emotional tone and variety in environment setting impact on the child’s learning.
Currently there are no globally agreed indicators for child development. The individual
child is assessed as outlined earlier in this chapter – cognitive, language and socio-
emotional development.

Social risks
These include maternal depression, exposure to domestic and community violence and
stigma and loss associated with HIV/AIDS. Studies suggest that women in developing
countries experience high levels of stress and depressive symptoms often associated
with poverty, lack of support and negative life events. Children of depressed mothers
are at risk because of inconsistent or unresponsive parenting. A Jamaican study has
shown that participation in parenting classes was associated with reduced levels of
stress, however the latter was not associated with improved cognitive functioning of
their children. Violence is often as a result of excessive corporal punishment, child
abuse or neglect. To date there is limited data on whether programs providing ‘social
protection’ to children mitigate against the adverse effects on development.






74
Environmental risks
Exposure to heavy metals such as lead and arsenic leads to irreversible brain damage.
Chelation of lead in exposed children reduces the plasma and bone content but has no
effect at all on development. The global shift away from leaded petrol has significantly
reduced the number of children exposed to lead. Arsenic is usually dissolved in water
from shallow wells. One intervention is to sink deep wells.



Infections
Control of infections – malaria and HIV/AIDS will reduce number of children at risk of
poor development. Cerebral malaria is associated with long-term neuro-cognitive
effects. The interventions are described in the respective chapters in this manual.

Investing in child development
Strategies that have been shown to optimize child development are characterized by;

Programs providing direct learning to children and their parents
Target the youngest and most disadvantaged child
Longer duration
High quality and high intensity
Integrate with family, health, nutrition and education services,

Current coverage of these programs is low. In order to meet the millennium
development goal of universal primary education, and poverty alleviation there is a need
to expand early childhood development programs. By 2005, only 15 developing
countries had made early childhood education compulsory.

Communities and governments are not aware of the children’s loss of developmental
potential, the potential cost of this loss on individual children and on poverty alleviation.
The lack of agreed on global indicators for measuring child development at population
level makes it difficult to monitor the interventions. Governments are faced with many
acute needs and therefore find it difficult to invest on long-term development. There are
also multiple groups interested in the young child resulting in a situation where no one
group takes responsibility. There is also the added challenge that there is no single
strategy for promoting child development.

Health workers need to advocate and promote early childhood development programs
with the understanding that events in early childhood affect learning and productivity
throughout life. Interventions in early childhood are cost effective improving efficiency
and effectiveness of education programs, in one intervention. Increased schooling for
girls has long term e3ffect on child survival and development. Early childhood
development programs are sustainable in that hey lead to development of new
standards and norms of rearing children.

Conclusions
Normal early childhood development is the foundation for a healthy life in the future. At
every contact the child’s development status should be assessed. Communities and



75
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 3
rd
Edition.







































76
CHAPTER 6

GROWTH MONITTORING AND PROMOTION
DURING EARLY CHILDHOOD

Daniel Njai, Rachel Musoke, Ruth Nduati, Aggrey Wasunna

INTRODUCTION
Growth is the gradual increase of the body size and shape and it consists of increase in
cell numbers and their size. The period from conception to age of 2 years is the fastest
growing period in life and is thus much more vulnerable. It is important to ensure
adequate growth during this period as insults occurring during this period are
irreversible. Growth depends upon adequate nutrition, appropriate physical and social
environment, as well as normal health. Up to the age of five years children around the
world have the same growth pattern if their health and nutritional needs are met. The
growth of a child, visibly displayed on an appropriate chart, is the most important
sensitive tool of measuring his health and nutritional status. When growth is charted
regularly over a period of time in infancy and early childhood, it is known as growth
monitoring. It is often done together with growth promotion as a combined operational
child survival strategy in Primary Health Care (PHC). It provides evidence of a child
who is growing well and helps to identify the child who is not growing well. When a child
is not growing well, appropriate health interventions such as treatment of illness and
provision of nutrition are carried out to promote good health and nutrition.

Growth monitoring is an essential component of paediatric health surveillance. This is
because any problem within the physiologic, interpersonal, and social domains may
adversely affect growth. Therefore, the growth of every child brought to a health unit
must be carefully assessed with a view to identify under-nutrition and failure to thrive.
Health workers have the important responsibility of using growth monitoring and
promotion (GMP) strategy to ensure that infants and young children have good health
and nutrition. The health workers, therefore, must acquire relevant knowledge, skills
and attitude to perform and manage growth monitoring and promotion in the
communities they serve. Growth and development are often considered together as it is
sometimes difficult to draw the line between the two. As you monitor growth is important
to assess development as well. In this chapter, you will learn about growth, measuring
growth, growth monitoring, factors that influence growth and development and what can
be done to promote optimum growth and development.

OBJECTIVES
At the end of the chapter the student should be able to:

Define growth
State the role of individual’s genetic constitution on growth and development
State other factors, besides the genetic constitution, which influence growth and
development
Explain the concept and strategy of growth monitoring and promotion as a means of
measuring and promoting health and nutrition of a child.



77
Understand the inter-dependency and the differences between growth monitoring and
promotion and nutritional assessment.
State the importance of growth monitoring in the under fives.
List four main objectives of growth monitoring through weight/age charts.
State the steps necessary for growth Monitoring and Promotion.
Measure the growth accurately, plot the measurements carefully on the growth chart
and correctly interpret the child’s growth pattern.
Report the measurements to the mother and inform her how her child is growing.
Counsel the mother
List the seven tasks of identifying growth monitoring needs in the community.
Recognize the role on integrating health education and operational research into
Growth Monitoring Programme.

LEARNING ACTIVITY
It is assumed that the student will visit the child welfare clinic and learn from the nurse
or doctor how to weigh babies accurately. Find out the kind of scale used. Plot the
weight of one or two children on the child health card. Find out whether the majority of
children are well nourished or not.

Importance of Growth Monitoring
Assessment of growth is very helpful in finding out the state of health and nutrition of a
child. Continuously normal growth and development indicate a good state of health and
nutrition of a child. Abnormal growth, or growth failure, is a symptom of disease. Hence,
measurement of growth is an essential component of the physical examination. Growth
monitoring enables health workers detect malnutrition early, facilitate early treatment or
correction of any conditions that may be causing abnormal growth and development and
to provide an opportunity for giving health education and advice for the prevention of
malnutrition.

Factors affecting growth and development
Each child’s path or pattern of growth and development is determined by genetic and
environmental factors. The genetic factors determine the potential and limitations of
growth and development. If favourable, the environmental factors, such as adequate
nutrition, facilitate the achievement of the genetic potential of growth and development.
Unfavourable factors acting singly or in combination, slow or stop growth and
development. Some of the unfavourable factors are malnutrition, infections, congenital
malformations, hormonal disturbances, disability, lack of emotional support, play,
language training and primary tender loving care provider. These environmental factors
can be removed or minimized. After the removal of an unfavourable factor, there is a
period of catch up growth. During the catch up growth period, the growth rate is greater
than normal. The greater growth rate continues until the previous growth pattern is
reached. Then the growth rate is reduced to the normal rate determined by the
individual’s genetic factors. A child with a genetic constitution supporting tallness grows
slightly more rapidly than a child with a genetic constitution supporting shortness.
Similarly, a child with a genetic constitution supporting cleverness develops more
rapidly than a child genetically constituted to be less intelligent.





78
INDICATORS OF GROWTH
The following measurements are used as indicators of growth. Weight-for-age, height-
for-age, weight-for-height, head circumference and mid-upper arm circumference.

Weight for age (WAZ)
Weight-for-age is the most widely used as it is easily done without too much training. It
however does not distinguish between acute (wasting) and chronic (stunting) nutrition or
fluid retention/loss. You need to have accurate weighing scales that are calibrated
regularly. The biggest draw back with this method is the determination of accuracy of
the child's age. The mother may have a written document supporting the date of birth or
she may remember accurately the date. Where the two do not provide the age, the
mother can be assisted to remember through seasons or event that occurred when the
child was born; hence the age can be ascertained.

As a general rule, birth weight doubles by 5-6 months, and triples at 12 months. As the
age increases the rate of growth gradually slows down.

Height for age (HAZ)
Height-for-age assesses linear growth. This measurement is of value in determining
stunting.
It is, however, more difficult to measure especially the length or height of infants and
young children. Accurate measurement of the young child requires a stadiometre and
training of the health worker.

Weight for height (WHZ)
This ratio is independent of age and helps in determining body build. It is a useful
measurement for distinguishing acute (wasting) from chronic (stunting) malnutrition.
Low weight for height (wasting) is more responsive to intervention than stunting.

Circumferences
Mid-upper-arm-circumference (MUAC)
MUAC not routinely used as growth monitoring tool but is very useful in assessing
nutritional status of infants and young children. Specific tapes have been designed with
different colour bands that help in screening for malnutrition in communities with limited
resources and who have minimally educated health workers.

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



79
hydrocephalus. Head circumference charts exist but are not included in country child
growth monitoring cards. The normal head circumference at birth is 34-36cms. The
head circumference increases 2cm/month for the first 3 months, the 1 cm/month in the
period 3-6months. In the period 6-12 months the head circumference increases
0.5cm/month. Overall the head increases by 10cms in the first year of life. The head
circumference is a sensitive way of identify children at risk of mental retardation
because of poor brain growth (microcephaly) or too large a head with hydrocephalous.

Waist circumferences and waist/hip circumference ratios are currently used to monitor
obesity in adults. Standard measurements for children have not been developed.

DEFINITIONS

Definition of Growth Monitoring and Promotion(GMP)

Growth monitoring is the regular and sequential weighing of the child, recording the
measurements on a growth chart. In doing so the growth can be easily visible and
demonstrated or explained to the mother. Growth promotion, on the other hand, is
giving the mother of such a child relevant and practical guidance within her means or
that of the family or the community on what to do to ensure growth continues well or
resumes, in case where it was not proceeding normally.

The process of growth monitoring combines identification, communication or
education for the individual mother, the family, the community and the health workers
on matters related to the growth, treatment of illness and improvement of nutrition.

Objectives of Growth Monitoring and Promotion
As discussed above, growth monitoring and promotion is a strategy which enables the
health workers assess normal growth of infants and young children. These two age
groups are vulnerable period of childhood and many factors may interfere with normal
growth. All infants and young children should have regular monitoring. On detection of
deviation from normal growth the health workers are able to assess and determine the
hidden problems such as in adequate nutrition or an infection. After identification of the
problem, the health workers can assist the mother and her family to make the right
decision regarding the most appropriate intervention required. Thereafter growth
monitoring is continued to see if the child catches up on normal growth. Children who
do not growth according to their potential, or who fail to achieve the expected
developmental milestones should be referred for specialist assessment.




The other objective of growth monitoring is to give mothers/parents/caregiver a chance
to meet regularly and to discuss what may be done to keep children healthy. Besides
use by health workers and parents regular growth monitoring and reporting to the
Ministry of Health helps planning and intervention at government level especially in
times of food shortage e.g. drought.




80


Performance of Growth Monitoring
Having grasped the concept of growth monitoring and promotion, the student should
learn to perform accurately the task of growth monitoring and promotion. Medical
officers require this skill in order to fulfill their roles as health workers and supervisors of
other health workers at health facilities and in the community. The following sub-tasks
or steps are important in performing growth monitoring and promotion.

Accurate and Safe Weighing of Infants and Children
Growth is progressive increase in body size resulting from multiplication of cells or
increase in size of the cells or both. Growth is measured by taking: weight, length (or
height), head circumference, mid upper arm circumference (MUAC). To be useful,
these measurements must be taken accurately using reliable equipment and correct
measuring techniques. To be reliable, the equipment must be calibrated regularly. For
measuring the weight, a beam balance or spring balance is used. The scale chosen
should be affordable, easily transported and durable. Different types of scales can be
used to measure a child's weight depending on the location of the activity. The
selection of the scale should take into consideration who will be using the instrument,
the working environment, and cost effectiveness. Weighing scales should be
affordable, easily transported and durable. Accuracy within 100g is acceptable.

It is recommended that the student finds out the most commonly used weighing scale in
his country, as types vary from one country to another. Students should be able to
describe the major parts of the scale. An example of a scale is the Salter Scale which is
widely used in community growth monitoring. This will be used to illustrate measuring
the weight for infants and children.

Major parts of Salter Scale: (See figure 1)
Upper hook (suspends scale with chain/rope from above)
Knob (adjusts pointer to zero)
Dial (reading of weight taken in kg)
Pointer (points to weight reading)
Lower hood (holds pair of pants which suspends child).

Each scale is usually supplied with four sets of strong plastic pants but other cotton
pants or a basket will do. Before weighing a child, the weighing scale is checked for
proper working. The checking is done through weighing a known weight and noting
whether that is the weight obtained from the scale. The scale is hung securely from a
roof beam or a tree with the dial of the scale at heath workers’ eye level for correct
reading.

There are five steps of taking the weight of a child:
Hang up the scale securely from the roof beam or a tree. The dial should be at eye
level to minimize errors in reading.
A pair of empty weighing pants is hung on the scale. The pointer of the scale is adjusted
to “0” by turning the knob on the top of the scale to account for the extra weight of the
pair of pants.



81


Figure 1: Growth monitoring using a hanging scale

























Let the mother prepare the infant for weighing by removing heavy clothes and shoes,
including the nappies.
After explaining to her that the baby is going to be weighed, the mother is asked to
dress the child with the weighing pants as shown in figure 1 above. The loops of the
pants are put over the lower hook of the scale. If old enough to understand, the child is
asked to hold on to the straps of the pants while the mother stands nearby, talking and
calming but not holding the child. The child’s feet should be off the ground as shown in
the picture in Fig. 1. A struggling child is calmed with the help of the mother.
When the child stops moving, the weight is quickly read to the nearest 10 gm in infants
and 100 gm in children. Help the mother to remove the child/infant from the sling
carefully

Measuring the head circumference – Child 0-24 months
The head circumference is measured by encircling the head with an un-stretchable tape
measure, or a piece of string in the absence of a tape measure.
Stand beside the child.
Put the tape around his/her head at the level of the largest perimeter, i.e. across the
bumps of the forehead above the supra-orbital ridges and the bumps of the occiput
posteriorly.



82
Take the measurement without compressing the head. Take the reading at which the
tape crosses the zero mark. Ensure that the tape is on the same plane.
The piece of string used in the absence of a tape measure is then measured with a ruler
to obtain the head circumference

Fig 2: Drawing showing measurement of the head circumference.

















Measuring the mid-upper arm circumference

Used in settings with limited resources, the mid upper arm circumference is measured
using a tape or string in the absence of a tape. MUAC is taken on the left arm using a
non-stretchable tape. Follow the 6 steps in measuring MUAC.

 Ask the mother to put the child on her lap or carry it in her arms.

 Request the mother to support the left arm of the child in a bent position.

 Identify by palpation the outer part of the acromion (prominent bone of the shoulder)
and the outer part of the olecranon (prominent bone of the elbow).

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

 Let the arm of the child rest loosely on the body (may be held). Put the tape around
the arm and take the mid upper arm circumference at this place, without
compressing the arm. The tape should be perpendicular to the axis of the arm. The
result is the value at which the tape is crosses the zero mark. Make the reading to
the nearest millimetre.




83
 Repeat the measurement and take the mean. If the two readings differ by more
than 5 millimetres, take a third measurement and keep the 2 closest readings).

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

See Fig 3: Drawing showing the measurement of mid upper arm circumference


























Measuring length and height
The length of a child is measured in the first 2 years and the height is measured after 2
years of age.
Crown-heel length - Child 0-24 months
 You require a measuring board to do this measurement as shown in figure 4. This
measurement requires the participation of 2 measurers (1 operator and 1 assistant).
Follow the following 7 steps in measuring the child’s length.
 The operator should ensure that the measuring rod is well fixed on a hard, flat and
horizontal table.



84
 Straighten the child on the table along the measuring rod and support the trunk of
the child while the assistant holds the child’s head with the hands and slowly puts it
on the fixed head bar of the rod as shown in figure 5.
 Ask the mother to stand near the child to help him/her stay calm.
 Hold the child’s head on the fixed part of the rod. The axis of the child’s eyes must
be perpendicular to the ground. Ensure that the child is straightened flat on the
table: shoulders and hips should be aligned, perpendicular to the axis of the body
and of the rod.

Figure 4: Height and Length Board


Height Board Length Board










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

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

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



85

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


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

Fig 6: Measurement of height in a child aged > 2 years














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



86
chart which is found on the Child Health Card. The growth chart is the second tool used
in growth monitoring and promotion. The student should familiarize himself with the
child health card used in his own country. One needs to understand the child health
card first.

The basic components of the health card are:
Personal details:
Child's name, registration number and sex.
Parent's name and address.
Birth dates.

Potential risk factors or reasons for special care:
Low Birth Weight.
Problem calling for special care such as low-birth weight, twins, large family, spacing of
less than 2 years, etc.
History of sibling death.

Use of Health Services:
Date when child is first seen.
Immunization record and national schedule for immunization.

Other key factors which may affect growth:
Breastfeeding.
Complementary feeding.
Child spacing.

Other possible components:
Treatment of diarrhoea.
Treatment of illness.

The graph on which the child's weight can be plotted against age is on the inside of
folded Child Health Card.

Please note the following (see fig. 2)
Horizontal lines represent weight of the child in kilograms or height in cms.
Vertical lines represent age of child in months.

WORLD HEALTH ORGANIZATION (WHO) CHILD GROWTH STANDARDS

These were launched in 2006 and many countries have adapted or are in the process of
adapting them to replace the older variety. They are truly international and are based on
the growth curves of breastfed infants. They establish breastfeeding as the norm for
early childhood feeding. The student should check in their respective countries how far
the adaptation process is. It may take a bit of time before the older ones are completely
phased out.
Note: the older charts which were being used in the region had only two lines. The
lower line represented the 3
rd
percentile weight for age for girls, and the upper one 50
th

percentile for boys. The new charts separate boys and girls, and include weight for age,



87
height for age. The generic charts have a middle line representing the 50
th
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



88
monitoring later and the birth weight is not known the first weighted is plotted in the box
that corresponds to the age of the child as shown in chart B. Chart C shows how to
locate the point to mark the weight of the child. The successive weights are connected
with a line on the growth chart as shown in chart D to produce an individual child’s
growth curve or pattern. This plotting of the weights on the growth chart is indispensable
in growth monitoring. Un-plotted, the individual weights indicate the sizes without
indicating whether the infant or child is growing well or not. You need to study a blank
growth chart to be thoroughly familiar with its contents see. When the growth curve is
plotted, the health worker and the mother can see at a glance whether the child is
gaining weight appropriately by watching the direction of the child’s pattern. The
direction is more important than the position of the curve on the child health chart.

Interpretation of the growth
It is very important to know how to interpret correctly the individual child’s growth on the
Child Health Card. Interpretation simply means determining whether the child is growing
appropriately or not. The interpretation is done by watching the direction of the child’s
growth pattern. The direction of the growth curve indicates how the child is growing.

Normal growth curve
A healthy child’s growth curve is parallel to the printed growth curves on the chart. It is
important to consider various factors in plotting and interpreting the growth of an
individual child. For the premature infants, over diagnosis of growth failure can be
avoided by subtracting the weeks of prematurity from the postnatal age when plotting
the growth measurements. The presence of a neurological abnormality such as cerebral
palsy in very low birth weight babies may limit catch-up growth.

Figure 8: A Good Growth Curve













The direction of the growth curve is more important than the position of the curve on the
chart. The weight growth pattern of the larger term infants will be above the pattern of
the average term infant. On the other hand, the weight growth pattern of the smaller
term infants will be below the pattern of the average term infant. A small baby whose
growth pattern is below the bottom line in the growth chart is healthy if that child’s
growth pattern is parallel to the bottom percentile line. As long as the baby is gaining
weight at an acceptable rate indicated by the baby’s growth curve being parallel to the
printed curves, the mother should not worry about the position of her child’s growth




89
curve on the child health card. Figure 9 below is an illustration of a child who is growing
well.

Fig 9: A normal growth curve




LEARNING ACTIVITY
To illustrate this we shall use the example of an infant called Wambui, born in
February 2008, whose birth weight was 3kgs, who attended a growth
monitoring session for the first time in July 2008, when his weight was 6.0kg.
He was seen again in September of the same year and he weighed 7.5kgs.
Write the name and birth weight in the right hand corner of the card. Print the
year 1994 at the beginning below the first box of the first year, and then
subsequent years. Print February in the first box of the first year, then fill the
subsequent months for each year. Place a dot in the middle of the column as
illustrated in figure 2, for the birth weight (middle of February) and the second dot
in the middle of July, September boxes, at the respective weights. Join all the
subsequent recordings (dots) with a straight line. Using this information, plot



90
Wambui’s growth on a growth chart on the blank child health card below. Is
Wambui’s growth adequate? Why do you say so?

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




Wambui’s growth curve is constantly going upwards. A constantly upward going curve
parallel to the printed lines shows GOOD growth. The mother, the person most
responsible for the child’s good health, is informed how her child is growing and praised
for her good efforts.

Horizontal growth curve

Fig. 11: A Static (horizontal) Growth Curve











91
A horizontal (flat) growth curve like the one in Fig. 11: horizontal growth curve. A
horizontal growth curve indicates DANGER! The horizontal growth curve means the
child is not growing, a sign of disease, especially malnutrition. A child who is
malnourished cannot grow properly, cannot resist diseases, and is in danger of getting
killer diseases. You should take a thorough history from the mother to establish the
cause of growth failure and then give the mother the relevant and practical guidance
within her means or the means of the family or of the community on what to do to
ensure continuation of normal growth or resumption of normal growth in case where
there was growth faltering manifested by horizontal or downward deviation of the growth
curve. The mother is encouraged to give the child food containing enough calories,
protein, vitamins and minerals. Thereafter, growth monitoring helps to determine the
adequacy or inadequacy of catch-up growth.

A downward growth curve

Fig 12: A Downward Growth Curve

















A curve deviating downwards, as shown in Fig. 12 A growth curve deviating downwards
, indicates a VERY DANGEROUS situation. The child is losing weight. The child needs
extra care immediately. The baby may be suffering from malnutrition, tuberculosis, AIDS
or other medical conditions. The mother is advised to take the baby to hospital for
investigations and treatment. Any infant who does not gain weight for one month or a
child who does not gain weight for two months should receive urgent attention. Such a
child is becoming malnourished.

Catch-up growth
Successful nutritional rehabilitation is associated with a growth spurt. During the growth
spurt there is a very steep increase in weight. The weight finally levels off at the
appropriate weight for height. The weight of HIV infected children may level off at low
weight for height. Increased caloric intake results in increased adipose tissue rather
than lean body mass.





92
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 5
th
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 5
th
month, the child ‘s weight gain slowed down and
eventually became static. As illustrated at the bottom right hand corner of the growth
chart, important events that affect the child’s growth should be recorded above the
weight on the Growth Chart. Such events include diseases, weaning, introduction of
solids and stopping of breastfeeding.

Fig 13. A horizontal growth curve






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



93
There are also weight for height charts and tables. Weight for height below the fifth
percentile is a good indicator of acute undernutrition. Measuring weight for length/height.
Weight for length/height is also used for monitoring growth. A child with acute severe
wasting has weight for length/ height Z score of -3. Such a child should be admitted for
treatment of malnutrition.
Growth monitoring will help you to detect growth failure early so that severe malnutrition
can be prevented. Growth monitoring should be continued up to the age of 5 years as a
component of well child care. Encourage parents to have their children weighed. The
health worker should avoid keeping the mothers waiting for too long and should have
the children undressed very shortly before their being weighed. You must always report
the findings to the mother or caretaker, inform her how the child is growing and counsel
her..

Consequences of Failure to intervene appropriately

Failure to intervene promptly through prompt treatment of illnesses and nutritional
rehabilitation or both, delays growth recovery and failure to recover the original
percentiles, important observations are.
Severe protein energy malnutrition combined with a
non-stimulating environment results in irreversible intellectual harm.
Adverse intellectual consequences of severe malnutrition can be modified by a
stimulating environment if it is introduced before the age of three years. Providing
increased stimulation and nutrition to at risk children significantly improves the
intellectual outcome of the children. Intervention before the age of three years yields
better results than later interventions.

Counseling the Mothers
Counseling the mother is the process of helping the mother to decide herself the best
action she can take to promote her child’s good health. This is the most important step
for the success of growth monitoring and promotion, whatever the educational level of
the mother. The health worker give information that is relevant to the child’s problem on
the material visit. The health worker deliberately builds on what the mother knows. At
the end of the session, the health worker asks the mother checking questions to
determine whether the mother has understood the instructions. The health worker
should avoid the closed (yes or no) questions and ask only the open questions (those
requiring the mother to give an explanation). The health worker should boost the
mother’s self-esteem by praising her whenever she answers or acts correctly.
Whenever the mother is doubtful about the instructions, the health worker should
carefully repeat the instructions and correct any mistakes in a sensitive manner.

Counseling of mothers can also be done in a small group. Such a group allows more
sharing of ideas and advice among the mothers themselves. The health worker
facilitates the discussion, listens to the mothers very attentively, and provides the
necessary information that the mothers can use to promote the health of their children.
The success of a mother whose children are growing well become the best source of
information for the advice to other mothers. Always remember that mothers are
concerned about the health and welfare of their children and they will do anything to
make their children grow well.



94
When Should Growth Monitoring and Promotion Start
In order to detect growth failure, growth monitoring should start as early as possible,
soon after birth, effective growth promotion focuses on the youngest ages and attempts
are made early to foster participatory action by mothers. There are two major
advantages of starting growth monitoring/promotion early:

Growth failure can be detected early for it to be corrected before the child becomes
malnourished
Growth promotion is easier to initiate in early infancy when positive growth can be used
as positive reinforcement. During early infancy mothers have more control over the
environment of their children, are prepared to devote more time and efforts to the health
of their children and can be effectively used as agents of change.

How Often and for how long should the Child be Seen for Growth Monitoring and
Promotion

The frequency of growth monitoring is determined by the velocity of growth and the
additional services that the child is being provided with such as immunizations. During
the first year of life there is rapid growth and development. The child makes a major
transition from intrauterine life to postnatal life and from being totally dependent on
breast milk to consuming an adult diet. These rapid changes make a child vulnerable to
malnutrition. Careful and frequent monitoring of growth enables prompt interventions.
The child should be monitored monthly in the first 24 months of life, 2-3 monthly in the
third year of life and then twice a year thereafter.

It is desirable that sessions of growth monitoring/promotion should coincide with
immunization visits in the first half of infancy in order to save the mother time and
ensure compliance.

KEY to a Successful Growth Monitoring Programme

Health worker training and motivation to participate in growth monitoring.
Participation of mothers in growth monitoring activities
Community mobilization for growth monitoring
Giving the mothers the growth chart to use as a passport into the health services
Sharing with mothers, families, school teachers and the community the meaning of the
growth chart
Encourage local people to take charge of the growth monitoring for example the local
pre-school facility may be the desired community facility for growth monitoring
Make sure that the waiting time is minimized and mothers are attended to promptly.
Utilize the time spend in the queue for health education in relevant topics.










95
CONCLUSION

The present chapter has outlined the role of growth monitoring and promotion in
promoting child health within PHC setting. GMP a low cost effective strategy is used to
visualize growth of young children to their mothers and health workers. Growth
monitoring also provides a tool for evaluating other interventions for promoting child
health. It provides education and communication stools for appropriate action to be
taken at the household level to support normal growth of children. Nutrition and health
information obtained as part of GMP should be used for re-assessment and modification
of ongoing child health intervention.


SELF EVALUATION QUESTION

Why is Growth Monitoring /Promotion important to:
an individual child
a community.

Discuss the major difference between nutritional assessment and growth monitoring
and promotion.

Compare and contrast a growth monitoring session at a health centre and at a village
outreach session. Point out the advantages and disadvantages of holding session at
each site.

Describe how you would set-up a growth monitoring/promotion programme in a small
rural fishing village.

Outline the role of health education in the promotion of growth monitoring in the
community.





96
BIBLIOGRAPHY

Cowman H: Growth Monitoring as a critical means to provide primary health care.
Indian Journal of Paediatric (Suppl.) 1988 55, 574 - 577.

De Onis M, Garza C, Victora CG et al. The WHO multicenter growth reference study
(MGRS): Rationale, planning, and implementation. Food and Nutrition Bulletin 25 No 1
(supplement 1) March 2004

De Onis M, Garza C, Onyango AW, Martorell R. WHO Child Growth Standards. Acta
Paediatrica Vol 95 (supplement 450) April 2006

Genece E., and Rhode J.E.: Growth Monitoring as entry point for Primary Health Care
Indian Journal of Paediatrics (Suppl.) 1988. 55.S 78 - 83.

Griffiths M. I Growth Monitoring: Making it a tool for education. Indian Journal of
Paediatrics (Suppl.) 1988. 55. 559 - 566.

Growth Monitoring UNICEF: Social statistics bulletin Vol. 6 1983 pp.1

Guide to health workers in Uganda. Ministry of Health Uganda.

Janeway C.: The State of Worlds Children 1983 pp 64.
Kenya Ministry of Health. How to use a child health card.. A Guide for Health Workers in
Kenya. Page 17.

King MH Nutrition for developing countries. A Weight for Age Graph Showing Growth
page 1.3 fig 1.7

Lalitha, N.V. and Standley: Training workers and supervisors in growth monitoring
Indian Journal Paediatrics (Suppl.) 1988 55, 548.

Morley D, and Woodland M. See them grow. McMillan Tropical Community Health
Manual. McMillan Press, 1979.

Rohde, J.E.: Beyond Survival; Promoting Health Growth, Indian Journal Paediatrics
(Suppl.) 1988 55 - 85.

Stanfield P, Brueton M, Chan M, Parkin M, Waterston T. Diseases of children in the
subtropics and tropics. ELBS Edward Arnold, Hodder and Stoughton, Kent (UK) 1991.

Acknowledgement – MR Kariuki Kamau for the help with the illustrations.





97
CHAPTER 7

CHILDHOOD IMMUNIZATION

Amos Odiit, Esther D. Mwaikambo


INTRODUCTION
Immunization as an element of primary health care is one of the most powerful and
cost-effective means of preventing infectious diseases but remains tragically
underutilized in many African countries. Percentage of one year old children who are up
to date with their immunization has risen from 20% in 1980 to about 80% in 2006.
However this still falls of the 90% target for developing countries Over the last few
years, Polio has been controlled in most African countries with only a few reporting
cases of wild polio virus. Measles mortality has reduced greatly, all of these following
mass immunization national immunization days. Pentavalent vaccine containing
Haemophilus Influenza type-B and Hepatitis B in addition to DPT has been introduced
in the region for the last 6 to 8 years. This has substantially reduced the mortality from
Haemophilus influenza type-B (meningitis and pneumonia). There is an ongoing
disease surveillance of vaccine preventable diseases that is also going to provide
information to help in the introduction of new vaccines in the region e.g. pneumococcal
and rota-virus vaccines.

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

List vaccine preventable diseases
Identify vaccine preventable diseases included in the EPI
Outline immunization delivery strategies
Describe immunization schedule and coverage in your country
Describe the procedures of administration of vaccines
Describe the vaccine cold chain
Outline the common problems to be anticipated in an immunization programme
Describe the efficacy of each EPI vaccine
Educate other health workers and the community of immunization
Evaluate immunization programmes
Indicate possible future developments in immunization

LEARNING ACTIVITIES
Observe health workers in a health care facility administering vaccines. Note the various
steps from the time the parents enter the facility to the time they leave. Evaluate the
health team performance.
Participate in administration of vaccine in the same facility under supervision of qualified
health worker
Note how the immunization programme in the facility is organized and what problems
the health workers encounter in performing their task



98
Interview five parents attending the facility picked at random and ask them when they
last brought their children for immunization and determine this was according to EPI
immunization schedule.

THE EXPANDED PROGRAMME OF IMMUNIZATION (EPI)

The expanded programme of immunization focus on eight diseases. Measles affects all
un-immunized children, kills over 2.0 million children annually. Pertussis kills about
600,000 children each year and causes severe complications in many others.
Neonatal tetanus is contracted through contamination of umbilical cord. It kills about
800,000 neonates per year. Tuberculosis attached each year about 10,000,000
children and can be very severe in young children. Polio has been the major cause of
lameness in developing world until recently. Diphtheria is now less common but kills
about 10 to 15% of its victims. Haemophilus influenza type-B has been one of the major
causes of bacterial meningitis and pneumonia in children until recently after introduction
of an effective vaccine.

Hepatitis-B does not manifest early in childhood, but children get infected as they grow
up and subsequently the disease may lead liver cirrhosis and cancer of the liver.
The challenges facing the immunization programme is to deliver basic vaccines to all
susceptible infants and tetanus toxoid to women of reproductive age.

STRATEGIES FOR DELIVERY OF IMMUNIZATION

The options in the delivery of immunizations are:
Fixed (static) facility delivery: this is the immunization services carried out in the health
facility whereby a child is brought to the facility for vaccination
Outreach immunization services. In this type of service the health workers travel from
the health facility to the community to deliver immunization
Mobile teams – health workers go from the health facility to vaccinate children from
house to house (using a mobile vehicle)
Intensive mass campaigns – this involves extensive sensitization of the communities
and the health workers delivering the service in designated points in the communities.

IMMUNIZATION SCHEDULES

Immunization scheduling is influenced by two biomedical factors.
The age at which the infant can develop active antibodies
The number of vaccine doses which must be given in order to evoke immunity. The
schedule varies from country to country











99
World Health recommended schedule is as follows:
AGE Vaccine

At Birth
BCG and OPV

At 6 weeks after birth

OPV2, DPT, Hib and HepB

At 10 weeks after birth

OPV3, DPT2 Hib2 HepB2

At 14 weeks

OPV4, DPT3, Hib3, HepB3

At 9 months

Measles
Key:
HepB B Hepatitis B Vaccine
Hib Haemophilus Influenza type-b
BCG Bacille Calmette Guerin
OPV Oral Polio Vaccine
DPT Diphtheria, Pertussis and Tetanus
It is recommended to give four does of Oral Polio in the first year of life. The first OPV
(OPVo) is given at birth or within the first two weeks after birth. The other three OPV
doses are given four weeks apart along with other vaccines as above. Extra doses of
OPV may be given at school age just after five years and at entry to secondary or
during national immunization days.

Interrupted immunization need not be started afresh. The remaining doses should be
given as if the prolonged interval has not occurred. Children who have their first contact
with EPI services after 6 weeks of age and less than 9 months should receive BCG, DT
and OPV first and continue OPV and DPT at four weeks intervals as above. An infant
encountered after two weeks of age forfeits OPVo and will have to wait for OPV one.

Five doses of Tetanus Toxoid (TT) to the mother will give longer immunity to the mother
and she will be able to pass adequate immunity to her offspring, preventing neonatal
tetanus.
The schedule for TT in women of reproductive ages


DOSE

MINIMUM INTERVAL

DURATION OF ROTECTION

TT1

STARTING DOSE

0 YEARS

TT2

4 WEEKS

3 YEARS

TT3

6 WEEKS

5 YEARS

TT4

ONE YEAR

10 YEARS

TT5

ONE YEAR

LIFE LONG



100
For pregnant mothers two doses may be given in first pregnancy at four weekly
intervals starting as early as possible. The rest of the TT doses may be given in the
subsequent pregnancies

ADMINISTRATION OF VACCINES AND IMMUNIZATION TECHNIQUE
Wash your hands before handling vaccines
Ensure that you are working in a clean and well organized environment
Clean and risk your equipment thoroughly before sterilizing them
If for sterilization you are using boiling methods, and then do the following:

Ensure that boiling water cover all the equipment and boil for at least 20 minutes
Ensure that sterilizer lead is properly in place during boiling.
For steam sterilizer read the manufacturer’s instructions and following them strictly
Use one sterile needle and syringe per injection per child

PRECAUTION IN HANDLING VACCINES

All vaccines must be stored between 0 - 8 degrees centigrade at all times
Ensure DPT and TT are never frozen while in storage between they their potency when
frozen.
Polio and measles are the most sensitive vaccines
Check expiry date and the name of the vaccine before drawing it for administration
Discard any opened but used vaccine at the end of day. Open a new vial even if only
one child remains to be vaccinated.
For BCG remember to reconstitute a new vial every four hours and avoid exposure to
light

VACCINE DOSE AND ROOT OF ADMINISTRATION

1. BCG is given intradermally into the deltoid area of the right upper arm
Since BCG dose varies with age and manufacturer careful read the manufacturer’s
instructions.
2. For OPV give two drops orally only
3. For DPT vaccine 0.5 mls. is given intramuscularly in the anterior mid thigh in the
quadriceps muscle.
4. Measles vaccine is given 0.5 mls IM in the deltoid muscle
5. Tetanus Toxoid for pregnant mothers is given I.M 0.5 mls in the left deltoid muscle.

Remember to tell the mother about the side effect of each type of vaccine given to the
child and advise her on what to do should they happen.

RECORD KEEPING

Enter daily immunization on to the summary sheet everyday
Record on the child health card the immunization given and the date in which they were
given.
Remember to give the mother a return date and stress the importance of completing all
the immunization.



101
COLD CHAIN MANAGEMENT

The cold chain is a system that ensures that the vaccines are kept between 0 and 8
degrees centigrade between transportation from the manufacturer to the people to be
vaccinated. The cold chain is necessary because the vaccine lose their potency when
exposed to higher temperatures. Successive exposures have cumulative impact on
vaccine potency. Once lost, potency cannot be restored. A typical cold chain consists of
four levels:

National
Regional or provincial
Health centre of hospital
Local health post or other location where vaccinations are carried out

Breaks in cold chain may occur at any of these levels
At every level of cold chain the key elements are:

Establish procedures for transport, storage and monitoring of vaccines
Have well trained well supervised personnel able to maintain and monitor vaccine
distribution according to established procedures
Well maintained equipment to store and transport vaccines at the proper temperature
In case of power failure remember to transport vaccines in a cold box to the nearest
district with power supply

IMMUNIZATION PROBLEMS

Lack of resources which include staff, supplies and equipment is the major constraint in
the delivery of effective immunization services in developing countries. In a tropical
environment with unreliable electricity supplies and lack of vehicles to carry vaccines
the cold chain is highly vulnerable to interruption with consequent loss of vaccine
potency.

Although no vaccine is total without adverse reaction, the risk of serious complications
of vaccines used in EPI is much lower than the risks of natural diseases. Important
reasons for the less than optimal immunization coverage include: postponement of
immunization of children, who are ill, who have upper respiratory tract infection, who
have fever, diarrhoeal diseases or who are malnourished. Yet these are the very
children who most need immunization.

There are no major contraindications to immunization. A severely ill child requiring
hospitalization may have immunization deferred but should have all the immunization
brought up to date before discharge.

An infant between 6 and 9 months of age seen in the health unit may be vaccinated
against measles when:

There is a measles epidemic
When there has been contact with a measles case



102
Such children vaccinated against measles before 9 months of age will have to be
revaccinated at one year.
Common side effects of vaccines are mild and severe ones are very rare:
Low grade fever with skin rash may occur for 4 – 7 days after measles vaccination
Reactions to oral polio vaccine, including paralysis similar to poliomyelitis, diarrhea,
perhaps one in every million doses
BCG vaccination will cause a small sore at the vaccine site. The sore usually
disappears after one or two months. Rarely this sore will become a chronic ulcer
BCG adenitis with abscess formation may occur
Most common side effects is local infection an abscess formation at the injection site
because of needle and syringe contamination
Infants with clinical AIDS should not receive live vaccines e.g. BCG or OPV, but should
be given the other vaccines.

EFFICACY OF VACCINES
Vaccines differ in their efficacy that is the ability to produce immunity in a susceptible
population vaccinated under optimal conditions. The table below shows efficacy of
various EPI vaccines.


VACCINE

%Vaccine efficacy

Measles

>95%

Polio

>95%

Diphtheria

>95%

Pertussis

>60%


Tetanus

>95%

BCG

Variable

HepB-B

??

HiB

??

HEALTH EDUCATION

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





103
EDUCATION AND SUPERVISION OF HEALTH WORKERS

Personnel in an immunization programme perform a wide variety of tasks ranging from
communicating with clients to carrying technical procedures. Training personnel to carry
out those tasks and supervising them is essential to the success of the immunization
programme. WHO, PAHO and UNICEF have developed courses and training materials
to teach supervisory and operational skills at all levels. In addition to this several
countries have established their own training programmes.

To ensure that all children needing immunization are properly vaccinated with potent
vaccines field workers must learn to:

ensure that cold chain is maintained at all levels.
give immunization talks both to individual child care-givers and to the whole population.
misconceptions about vaccination are detected and addressed optimally
integrated surveillance for vaccine preventable diseases is established and maintained

A good system is essential to a successful programme and people always work more
carefully when they know that their performance is being evaluated. The essentials of
good supervision are:


Sufficient funds for supervision at all levels
Frequent supervisory visits to the field
Written job descriptions specifying performance standards of all tasks.
Check list to guide supervisors in evaluating performance
Recognition of good performance by supervisors
Investigations to determine reason for poor performance and to develop strategies for
improvement.
Standard training programme for supervisors

COMMUNITY AWARENESS AND INVOLVEMENT IN IMMUNIZATION

Most of the effective immunization programmes have included aggressive
communication activities. It does little good to provide immunization services unless
parents are convinced that immunization is valuable, know where and when services
are available and understand when children should receive vaccines.

There are three important components of communication strategy:

Audience – the main audience of immunization programme are parents of young
children
Messages – these perform a dual role, first to create public awareness and support, and
secondly to provide specific information that people need in order to use immunization
services. The a message to be effective it should be compatible with audience attitudes,
beliefs and experience
Communication channels – mass media can reach most people but person to person
communication and other strategies are important to re-enforce these media particularly



104
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.





105
CHAPTER 8

CONTROL OF DIARRHOEAL DISEASES

Israel Kalyesubula

INTRODUCTION

Diarrhoea is defined as the passage of three or more, watery or loose stools in a 24
hour period: a loose stool being one that would take the shape of the container. It is
described as acute diarrhoea if it has lasted less than 14 days; persistent diarrhoea if it
has lasted beyond 14 days and dysentery if the stools are bloody.

It is one of the leading causes of illness and death among children in developing
countries. It is estimated that 1.3 thousand million episodes of diarrhoea and 3.2 million
deaths from diarrhoea occur annually among children under five years in the developing
countries. Overall, children experience an average of 3.3 episodes of diarrhoea per
year. In some areas, the average exceeds nine episodes per year.

Diarrhoea contributes about 25-30 per cent of the total deaths in the under fives. About
80 per cent of deaths occur in the first two years of life. The main cause of death from
acute diarrhoea is dehydration, which results from the loss of fluid and electrolyte in the
diarrhoeal stools. Other contributory factors include: preexisting malnutrition serious
undercurrent infections such as pneumonia and delay in seeking care in cultures that
believe that the diarrhoea is due to “false” teeth that would need to be extracted.

Diarrhoea is an important cause of malnutrition by reducing appetite, and reduced
absorption of nutrients. A vicious cycle is created as malnutrition predisposes to
increased frequency of infective and persistent diarrhoea which worsens the
malnutrition.

Correct case management of diarrhoea both at home and at health facilities saves
many lives. This includes the use of hypo-osmolar oral rehydration salt (ORS) solutions
combined with zinc supplements. Antibiotics are used in selected types of diarrhoea.

OBJECTIVES
At the end of this chapter the student should be able to:
Define diarrhoea
Outline the difference between acute and persistent diarrhoea
Describe the role of diarrhoea on the burden of illness in children in the developing
countries
List the risk factors for diarrhoea morbidity and mortality in children
List the viral, bacterial and parasitic causes of diarrhoea
Describe the pathophysiology of diarrhoea
Describe the complications of diarrhoea and explain how diarrhoea causes dehydration
and malnutrition
Describe dysentery and persistent diarrhoea



106
Describe the standard case management of diarrhoea: assess, classify dehydration and
manage diarrhoea
(10) Describe traditional methods of treating diarrhoea and their complications

(11) Describe dangerous methods of treating
(12) Outline the strategies for prevention and control of diarrhoea in children
(13) Explain the role of appropriate feeding in diarrhoea

LEARNING EXPERIENCE
Practice proper history taking in a child with diarrhoea, with emphasis on detecting the
severity of dehydration
Observe and participate in assessing the degree of dehydration
Calculate the amount of fluids required by a child with some dehydration and assist the
mother in giving ORS to her child
Demonstrate to the mother how to prepare ORS
Advise the mother on how to manage and prevent diarrhoea at home
Using the case illustration given below, the student to perform role play, with one
student acting the health worker role while the other acting the mother role
Review epidemiology, aetiology and pathophysiology of watery diarrhoea
Review the diarrhoea case management video

CASE ILLUSTRATION 1
Monde, a 12 months female from Kalingalinga shanty compound is brought to a local
hospital with a two day history of diarrhoea and vomiting. The child was previously well
and was breast fed for six months only. The mother who is single had to start work as a
house help, so her 12 year old sister who is a school drop out looks after the child while
the mother is at work. She feeds the child on maize meal porridge and fresh cow’s milk.
They draw water from a well one kilometer away and the family uses a pit latrine.
On examination the child is afebrile. She is restless, irritable, and has sunken eyes. She
is thirsty and drinks eagerly and the skin pinch goes back slowly.

Problems to solve.
Using the above case, carry out a role play with one student acting the role of a health
worker and the other the role of the mother. In the process assess, classify and manage
Monde and give the mother advice on how she should take care of Monde at home.
Use the list below to help you in the role play
1. List all Monde’s signs of illness
2. Record how you would classify Monde’s dehydration and list all the signs that you
use to classify the dehydration
3. Look at the treatment plan under the classification in which you put Monde and
describe how you would manage her.
4. What would you tell Monde’s mother about how to treat the child at home? What
would you do to help her manage the child at home?
5. What would you tell her about how to manage the next attack of diarrhoea in case it
occurs?
6. What would you tell her about how to prevent occurrence of similar attacks in future?





107
CASE ILLUSTRATION 2
Mukasa is a six month old male from Kisugu who was admitted in Kawempe health
centre 10 days ago with diarrhoea. His condition appears to have deteriorated with
swinging temperatures. He refuses to breast feed and appears to be uncomfortable and
crying most of the time. On examination Mukasa looks toxic and in pain.
Problem to solve
List all Mukasa’s signs of illness
Record how you would review Mukasa’s history of his illness, emphasizing previous
treatments before admission to the health centre.
Reexamine Mukasa to establish the possible cause of Mukasa’s illness.
How should the health centre staff have managed this baby?

AETIOLOGYAND EPIDEMIOLOGY

A quick guide to aetiological causes of diarrhoea:

Diarrhoea with no fever and no blood in stool
Rota virus
Cholera
Food poisoning etc
Diarrhoea with fever and blood in stool
Shigella
Escherichia coli etc
Diarrhoea with blood in stool but no fever
Amoebic dysentery
Salmonellosis (typhoid in infants)
Diarrhoea with fever and no blood in stool:
Otitis media
Pneumonia
Urinary tract infection
Meningitis
Malaria etc

N.B: Students should widely consult and fill in and expand this table.

Types of diarrhoea

Three clinical syndromes of diarrhoea described below have been defined, each
reflecting a different approach to treatment.

Acute watery diarrhoea

The term refers to diarrhoea that begins acutely, lasts less than 14 days and involves
the passage of frequent watery stools without visible blood. Vomiting and fever may be
present. Acute watery diarrhoea causes dehydration and when food intake is reduced, it
also contributes to malnutrition. The main cause of death in acute watery diarrhoea is
dehydration often associated with delay in seeking care and inappropriate treatment at
home or in the health facility. Health workers must be aware of complications of



108
anaemia and septicaemia as a result of traditional healers extracting infants’ teeth by
way of managing diarrhoea. The most important causes of acute watery diarrhoea in
young children in developing countries are rota virus, Escherichia coli, Campylobacter
jejuni, Vibrio cholera and Cryptosporidium.

Dysentery
This is diarrhoea with visible blood in the stool. Important effects of dysentery include
anorexia, severe abdominal pain and rapid weight loss. The main cause of dysentery is
Shigella. Some types of Escherichia coli and Salmonella may also be a cause.
Entamoeba histolytica can cause dysentery but it is rare in young children.

Persistent diarrhoea
This is diarrhoea that begins acutely but the duration is 14 days or more. It may begin
either as watery diarrhoea or as dysentery. Marked weight loss is frequent and
dehydration is a frequent finding. There is no single microbial cause for persistent
diarrhoea, shigella, enteropathogenic E. coli and cryptosporidium may play a greater
role than other causative agents. About 10 percent of acute diarrhoea episodes become
persistent. It is commonly associated with malnutrition, recent introduction of animal
milk feed, young age intercurrent infections and infection and immunological
impairment. It is associated with increased mortality, contributing to 35 percent of the
diarrhoeal deaths.

Epidemiology of Diarrhoea
Transmission of agents that cause diarrhoea
The infectious agents that cause diarrhoea are usually spread by the faecal-oral route,
which includes the ingestion of faecally contaminated water or food and direct contact
with infected faeces.

Risk factors for diarrhoea

Failing to breast feed exclusively for the first 6 month
Poor complementary feeding practices including hygienic preparation of food
Using infant feeding bottles
Storing cooked food at room temperature
Using drinking water contaminated with faecal bacteria
Failing to wash hands:
After defaecation
After disposing of faeces or
Before handling food
Failing to dispose of feaces hygienically
Poor personal and domestic hygiene
Lack of immunizations
Malnutrition
Measles infection
Immunodeficiency or immunosupression states






109
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
1
owing 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.
























110
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.





111
Campylobacter jejuni
In developing countries, C. jejuni causes disease mostly in infants. It also infects
animals, especially dogs and chickens and is spread by contact with their feaces or
consumption of contaminated food, milk and water.
Vibrio cholera
V. cholera causes non-invasive diarrhoea which is mediated by toxins and extensive
coverage of the villae by the bacteria adhering to their surfaces. Antimicrobials can
shorten the duration of the illness. Tetracycline is widely used, but because of
resistance, other antimicrobials effectively used are cotrimoxazole, furazolidine or
chloramphenicol.

Enteric pathogens can also be found in about 30 percent of healthy children, making it
difficult to know whether a pathogen isolated from a child with diarrhoea is actually the
cause of that child’s illness. This is especially true for Giardia lamblia, enteropathogenic
E. coli and Campylobacter jejuni. On the other hand, Shigella and rotavirus are rarely
identified in healthy children, their presence in a child with diarrhoea is a strong
aetiological evidence.

Table 1 shows that antimicrobial agents are recommended only when infections with
shigella or V. cholera is suspected on the basis of clinical signs (especially in
epidemics) or confirmed by laboratory investigations. For all other agents and thus the
majority of acute diarrhoea episodes in young children, antimicrobials are either
ineffective or inappropriate. For agents such as salmonella the use of antimicrobials can
actually prolong the intestinal infection.
A number of other pathogens are not shown in Table 1 can cause acute diarrhoea in
children in developing countries but their role is either minimal or not well defined yet.
They include a number of viruses, bacteria and protozoa.

Other conditions associated with diarrhoea (see the guide to aetiological causes of
diarrhoea)
Children with infections such as malaria, urinary tract infections and other systemic
infections may present with diarrhoea. It is important that these conditions be identified
and appropriate treatment be given besides ORS. NB: Never give antibiotics to a child
presenting with diarrhoea and fever before confirming the absence of meningitis. It may
lead to partially treated meningitis with subsequent permanent mental damage.

PATHOGENESIS AND PATHOPHYSIOLOGY
Pathogenetic Mechanisms
Generally this is either by destruction of intestinal epithelia or toxin production. The loss
of the normally absorptive villous cells and their temporary replacement with immature
secretory crypt cells, causes the intestines to secrete water and electrolytes. Villous
damage is also associated with a loss of disaccharidase enzymes, leading to reduced
absorption of disaccharides, especially lactose. Recovery occurs when the infected cells
are replaced by healthy ones in 2-4 days.
Toxins alter epithelial cell function and reduce absorption of sodium by the villus and
increase the secretion of chloride in the crypts, leading to secretion of water and
electrolytes.




112
Viruses such as rotavirus, replicate within the villous epithelium of the small bowel,
causing patchy epithelial cell destruction and villous shortening.

The pathogenic bacteria cause diarrhoea by:
Production of a toxin (secretory diarrhoea), as happens with enterotoxigenic E. coli and
V. cholera. Invasion and destruction of epithelial cells (invasive diarrhoea), as occurs in
shigella, enteropathogenic E. coli, C. jejuni and salmonella infections. The protozoa
such as Giardia lamblia and cryptosporidium adhere to the small bowel epithelium and
cause shortening of the villi, which may be how they cause diarrhoea.

Pathophysiology
Watery diarrhoea is caused by a disturbance in the mechanism of transport of water
and electrolytes especially sodium and chloride in the small intestines, and this is the
basis of management of diarrhoea through oral rehydration therapy and feeding.
Normally, sodium is actively absorbed from the bowel lumen by the villous epithelial
cells (Fig.1). After this sodium is transported out of the epithelial cells into the
extracellular fluid (ECF) by an ion pump known as Na
+
K
+
ATPase. This creates an
osmotic gradient that facilitates absorption of water. There are several mechanisms
through which sodium is absorbed in the gut (Fig 2). Sodium linked to chloride iron
direct as sodium ion

Exchanged for hydrogen ion and linked to the absorption of organic substances such as
glucose or amino acids, a mechanism that is less affected even under disease
conditions. Secretion of water and electrolytes on the other hand occurs in the crypts of
the small bowel epithelium where sodium chloride is transported from the ECF into the
epithelial cells where sodium is pumped back into the ECF, but chloride is passed into
the lumen. Interference with these two mechanisms leads to more secretion than usual
plus reduced absorption as occurs with infections, will lead to diarrhoea.

CONSEQUENCES OF WATERY DIARRHOEA
Patients with watery diarrhoea produce stools containing large amounts of sodium,
chloride, potassium and bicarbonate ions.

Average electrolyte content, mmol/l
Na
+
K
+
Cl
-

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



113
All the acute effects of watery diarrhoea are caused by the loss of water and electrolytes
from the body. Additional amount of water and electrolytes are lost when there is
vomiting. It is further increased by fever. These losses lead to dehydration, acidosis and
potassium depletion. The water and electrolytes loss are normally compensated for by
water and salt intake in drinks and food.

Complications of severe diarrhoea include shock, acute renal failure, malabsorption,
anaemia, convulsion and death.

DEHYDRATION
This is the most dangerous complication because it can cause decreased blood volume
(hypovolaemia), cardiovascular collapse and death if not treated promptly. Dehydration
is more severe in children because, children have a higher percentage of body water
(70-75 percent) compared to adults (55-60 percent). In addition, water intake in children
is less and vomiting is more frequent contributing to the fluid deficit.
Biochemically, dehydration can be classified as: isotonic, hypotonic and hypertonic.

Isotonic dehydration

This is the most common type of dehydration caused by diarrhoea. There is equal
loss of water and electrolytes and it is characterized by:
Balanced deficit of water and sodium
Normal serum sodium concentration (130-150 mmol/l)
Normal serum osmolarity (275-295 mOsmol/l)
Substantial loss of extracellular fluid

Hypotonic dehydration

Loss of electrolytes more than that of water. There may be excess intake of plain
water, or intravenous infusion of 5 percent glucose in water. It is characterized by:
Deficit of water and sodium but with a greater deficit of sodium
Low serum sodium concentration (<130 mmol/l)
Low serum osmolarity (<275 mmol/l)

Hpertonic dehydration

There is increased water loss compared to electrolyte loss. May result from increased
intake during diarrhoea of hypertonic fluids (such as sugar salt solutions) or
insufficient intake of water. It is characterized by:
Deficit of water and sodium but there is more water deficit
Elevated serum sodium concentration (>150 mmol/l)
Elevated serum osmolarity (>295 mOsmol/l)
Severe thirst out of proportion to the degree of dehydration
Seizures may occur, especially when serum sodium concentration exceeds 165
mmol/l






114



PRINCIPLES OF MANAGEMENT OF DIARRHOEA AND DEHYDRATION

Rehydration therapy
The goal in managing diarrhoea is to correct deficit of fluid and electrolytes
(rehydration therapy), and then replace further losses as they occur until diarrhoea
stops (maintenance therapy). The mainstay of management of diarrhoea is oral
rehydration therapy (ORT) supported by zinc supplementation. The majority of
diarrhoea and dehydration are effectively managed by use of this method. Only in very
severe dehydration, is intravenous rehydration indicated during the resuscitation phase,
followed by ORT.

Feeding
All children with diarrhoea should be given plenty of food to prevent malnutrition. For
children less than 6 months continue breast feeding. Breast milk is the best food for
young babies. If the child is six months or older, or is already taking solid food, give
cereals or another starchy food mixed with vegetables, pulses, meat and fish. Add one
or two teaspoonfuls of oil to each serving to increase energy supply.
Dairy products and eggs are also suitable foods for children with diarrhoea. Fresh fruits
or fresh juices should be given because they provide potassium. During the diarrhoeal
episode, offer food more frequently at least six times a day. After the diarrhoea stops,
offer the same food and give an extra meal each day for two weeks.

Antimicrobials in the treatment of diarrhoea
Although pathogenic organisms can be isolated in about 75 percent of patients with
diarrhoea, the majority do not need antibiotic treatment. ORS together with zinc
supplements is adequate treatment. The only diarrhoeal diseases in which antibiotics
are indicated are:
Shigella
Vibrio cholera and
When there are intercurrent infections such as pneumonia urinary tract infection.
Always look for signs of meningitis and give appropriate antibiotic cover.
Antidiarrhoeal (antisecretory and antimotility) drugs
There are no indications for these drugs in diarrhoea, they neither reduce the frequency
nor the duration of diarrhoea and some of them are contraindicated.

ASSESSMENT OF THE PATIENT WITH DIARRHOEA
Every child who presents with diarrhoea should be carefully assessed before his or her
treatment is planned. Clinical assessment consists of a brief history, including previous
treatment attempted, and examining the child.
Its objectives are to:
Detect dehydration and degree of dehydration by using standardized clinical features
(IMCI)
Diagnose dysentery if present from history of bloody diarrhoea
Diagnose persistent diarrhoea from the duration of the diarrhoea
Determine the patient’s nutritional status



115
Diagnose concurrent illness, such as meningitis, septicaemia resulting in some
traditional treatment of diarrhoea and pneumonia
Determine the child’s immunization status, especially that of measles
Delete the sections highlighted and use table 12 in the WHO pocket book of Hospital
care for children

Assessing and management of a child for dehydration
Detection of dehydration is based entirely on signs observed as shown table 3 below.
Table 3 Assessment for dehydration

General Condition
*
Well, alert Restless or Lethargic
or
irritable
unconscious floppy
Eyes Normal Sunken Very
sunken and dry
Thirst
*
Drinks normally Thirsty, drinks Drinks
poorly or
not thirsty eagerly unable to
drink
2. FEEL
Skin Pinch
*
Goes back Goes back Goes
back
quickly slowly very
slowly > 2 seconds
DECIDE: (Classify) NO SIGNS OF SOME
SEVERE
DEHYDRATION DEHYDRATION
DEHYDRATION
TREAT: Use plan A use plan B Use
Plan C

*
Key signs

NB skin turgor is not reliable in a malnourished child. Sunken fontanelle in babies can
also be used.
A child is in shock when the following are present: cold extremities, weak peripheral
pulses, low blood pressure and reduced urine output.
To decide on the presence and degree of dehydration of dehydration, one needs at
least 2 (two) of the four signs shown in Table 3. Once the degree of dehydration has
been made, the treatment plans A, B or C should be used as appropriate.











116

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


Age < 4
months
4-11
mo
12-23
mo
2-4 yrs 5-14 yrs 15 yrs and
older
Weight < 5 kg 5-7.9
kg
8-10.9
kg
11-15.9
kg
16-29.9
kg
30 kg or
more
In mls. 200-400 400-
600
600-800 800-1200 1200-
2200
2200-4000
In mls.
based on
75
mls/Kg
375 592.5-
600
817.5-
825
1192.5-
1200
1200-
2242.5
2250

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



117
oedematous (kwashiorkor or marasmic kwashiorkor) or severe non-oedematous
malnutrition (marasmus). Children who are malnourished must be given prescribed
feeding treatment to provide 100-200 calories per kilogramme body weight per day and
four (4) grammes of protein per kilogramme body weight per day.
Figure 6: Assessment of the Patient for other problems


ASK ABOUT BLOOD
IN THE STOOL

ASK WHEN IF DIARRHOEA HAS LASTED AT LEAST 14 DAYS
Refer to hospital if:
The child is under 6 months
Dehydration is present (refer the child after treatment of dehydration)
Otherwise, teach the mother to feed her child as in plan A except:
Replace animal milk with a fermented milk product such as yoghurt
Assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed
with vegetables, pulses, meat or fish.
Tell the mother to bring the child back after 5 days:
If diarrhoea has not stopped, refer to hospital
If diarrhoea has stopped tell the mother to|
Use the same foods for the child’s regular diet
After 1 more week gradually resume the usual animal milk
Give an extra meal each day for at least 1 month.

LOOK FOR SEVERE UNDERNUTRITION

ASK ABOUT FEVER ANDTAKE TEMPERATURE


PREVENTION OF DAIRRHOEA
It is important to teach communities on steps to prevent diarrhoea and these include:
Exclusive breastfeeding
Appropriate complementary feeding
Hygienic preparation and storage of food at all times
Clean drinking water
Hand washing before feeding and use of the toilet
Safe disposal of stools for all (including those of small children)
Complete immunization especially measles

REFERENCE:

WHO Pocket book of Hospital care for children




118
CHAPTER 9

ACUTE RESPIRATORY INFECTIONS IN CHILDREN

Elizabeth Maleche-Obimbo and Ezekiel M Wafula

INTRODUCTION
Acute respiratory infections (ARI) can be divided into upper respiratory tract infections
(URTI) and lower respiratory tract infections (LRTI). The former consists of common
cold, otitis media, sinusitis, pharyngitis, and tonsillitis, while the latter includes laryngo-
tracheobronchitis (LTB), bronchiolitis, and pneumonia.

Learning Objectives
By the end of this chapter, the student should be able to:

Describe the anatomy of the respiratory system
Outline the aetiology and epidemiology of acute respiratory infections in children in
developing countries.
Discuss the diagnosis and management of acute infections of the upper respiratory
tract.
Discuss the diagnosis and management of acute infections of the lower respiratory
tract.
Understand how to prevent morbidity and mortality from acute respiratory infections.

Learning Activities
Assess, classify and outline treatment of children presenting with cough and difficulty in
breathing to the out-patient department
Participate in the management of a child admitted to the ward with severe pneumonia
from admission to discharge.
Manage a child presenting to the hospital with stridor.
Review the integrated management of childhood illness (IMCI) slides and/or video
covering the topic of acute respiratory infection in children
Familiarize yourself with the standardized ARI case management charts provided by
IMCI on child presenting with cough, and with stridor.

The Anatomy of the Respiratory System
The upper respiratory tract includes the nose, ears, naso-pharynx, pharynx, tonsils and
larynx. Any structure below the larynx is part of the lower respiratory tract, including the
trachea, bronchi, bronchioles, lung parenchyma, and pleura.

Epidemiology of Acute Respiratory Infections
ARI is common in children under five years, in whom four to eight infections occur per
year. ARI accounts for 40 – 60 percent of the children in outpatient clinics, and 30 – 50
percent of paediatric admissions, an indication of the high magnitude of the condition.

ARI is the most common cause of mortality in infants and young children. It contributes
to 20 – 50 percent of deaths among children less than five years of age in developing
countries. The majority of ARI deaths are due to pneumonia, a LRTI. Pneumonia



119
together with diarrhoeal disease, malaria, malnutrition and human immunodeficiency
virus (HIV) infection contribute to over 75% of all the deaths in children under five years
in developing countries. This signifies the seriousness of these five childhood diseases.

Among children under 5 years, ~1 in every 3 children will have an episode of
pneumonia within a year, and approximately 10% will require hospital admission. In
2002 the World Health Organization (WHO) estimated that pneumonia contributes to an
estimated 15-25% of childhood deaths in Sub-Saharan Africa; and according to regions,
contributes to 15-20% mortality in Southern African countries, and 20-25% of mortality
in Eastern, Central and Western African countries.

Risk Factors for LRTI
Various factors prevalent in resource-poor settings contribute to increased risk for ARI
in children. These factors include high prevalence of underlying illness such as
malnutrition and HIV infection; high prevalence of other tropical diseases such as
malaria, diarrhoea and measles; environmental factors such as overcrowding and
indoor pollution from cooking fuels such as wood, charcoal or kerosene.

Malnutrition a common disorder in children is a very significant risk factor for ARI in
children. Available evidence shows that prevalence of pneumonia among severely
malnourished children is as high as 72%, and that pneumonia occurs 19 times more
commonly in malnourished compared to well nourished children, and that pneumonia
death is 27 times more frequent in this high risk group.

Aetiology of Acute Respiratory Infection
The majority of URTI are due to viruses. Acute tonsillitis, streptococcal pharyngitis and
retropharyngeal abscesses are predominantly due to bacterial infection.

Bronchiolitis is commonly caused by viral infections of the lower respiratory tract,
including respiratory syncytial virus, parainfluenza and influenza viruses among others.

Aetiology of Pneumonia
In developing countries, bacteria account for 30-60% of pneumonia, viruses for 25-40%,
and atypical pathogens such as opportunistic organisms for up to 25%. Mixed bacterial-
viral infection account for 10-15% of pneumonias. The specific aetiology (especially
with respect to bacteria) varies according to age of child, presence of malnutrition or of
underlying HIV infection.

In young infants (under 2 months) common bacterial causes of pneumonia include
group B beta haemolytic streptococcus, gram negative bacteria such as E coli and
Klebsiella pneumoniae, and Chlamydia trachomatis. Viral pneumonia is not common in
this age group.

In infants and young children under five years most common bacterial pathogen is
streptococcus pneumonia, followed by Haemophilus influenzae, and staphylococcus
aureus. In the older child in addition to streptococcus pneumonia and staphylococcus
aureus, mycoplasma pneumoniae, and Chlamydia pneumoniae cause disease.



120
In addition to the above described pathogens, severely malnourished and HIV infected
immuno-suppressed children, are prone to gram negative bacterial pneumonia and
pneumocystis jiroveci pneumoniae (PCP), the latter seen especially in HIV infected
children under age 6 months and severely immuno-suppressed.

Viral causes of pneumonia in children include respiratory syncytial virus (most
common), parainfluenza virus, influenza virus and adenovirus. These viral infections of
the lower respiratory tract may frequently manifest as croup or bronchiolitis.

Standard ARI Case Management
The traditional approach in the diagnosis of respiratory syndromes, especially of
pneumonia, is known to be associated with frequent mis-diagnosis. Effective control of
pneumonia requires early detection, and institution of appropriate antibiotic therapy.

Guidelines developed by the World Health Organization (WHO) and UNICEF for
management of a child presenting with ARI emphasize the recognition and
management of ARI at out-patient level, be it at the dispensary, health centre, or
hospital out-patient department. They are simple enough to be effectively used by
community health workers and mothers to recognize early pneumonia, and therefore
seek attention early.

The detection of pneumonia is based on two important clinical parameters; respiratory
rate and chest indrawing. Every child presenting to an out-patient facility with history of
cough and/or difficult breathing must undergo a thorough assessment, their illness
diagnosed and classified, and given appropriate treatment. If the parent does not give
history of cough and/or difficult breathing, the health worker must inquire about it.
Ultimately it is most important to differentiate very sick children needing in-patient
management from those that are less sick and may be treated at home.

For objective management, the children are divided into two groups based on age as
follows: two months to five years (the young child) and under two months (the young
infant). This is shown in figures 2 and 3.

Assessment of Children with Cough and/or Difficult Breathing

Every child presenting with cough and/or difficult breathing, it is important to determine
age, duration in days, whether they are breathing fast, have difficulty in breathing,
stridor or wheeze, fever, whether there is history of exposure to someone with TB in the
family, history of choking or sudden onset, know HIV infection, whether child has been
immunized against BCG, DPT, Hib or measles, and if there is personal or family history
of asthma. It is also important to determine if the child has symptoms suggesting very
severe illness as follows:

Danger Signs
In assessing the child with ARI, it is important to ask and look for clinical features or
“danger signs” that suggest severe illness, and are associated with high mortality risk.
Any child presenting with these danger signs (listed below) should be admitted into the
hospital for care.



121

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 (≥ 38
0
C) or hypothermia (< 35.5
0
C)?
The young infant is given special attention, because their ARI mortality is higher, and
their disease presentation and treatment are significantly different from older children.
Bacterial infections in young infants may present with non-specific clinical signs, making
it difficult to distinguish pneumonia from sepsis and meningitis, and can lead to severe
illness and death rapidly.

The differential diagnosis of a child presenting with cough or difficult breathing is
outlined in table 1 below.



122
Table 1: Differential diagnosis of the Child Presenting with Cough
or Difficult breathing



Classification of Children with Cough and Difficult Breathing

After assessment, a child aged two months to five years with ARI should be placed into
one of the following categories of ARI:





123
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.



124
Table 2: Classification of the Severity of Pneumonia



Treatment

Guide to treatment is as outlined in the table 2. Specific details on antibiotic therapy,
oxygen and supportive care are outlined in the following paragraphs.

Antibiotic Therapy

Antibiotics for very severe pneumonia
Antibiotics should be given for 10 days in children with very severe pneumonia.
Give intramuscular (IM) or intravenous (IV) ampicillin (15mg/kg every 8 hours) and
gentamicin (7.5mg/kg once a day) for 5 days.
If child improves, complete the treatment at home or in hospital with oral amoxicillin
(15mg/kg three times a day) plus gentamicin once daily for a further 5 days

Alternatives:
IM or IV chloramphenicol (25mg/kg every 8 hours) until child improves, and then
continue oral chloramphenicol 4 times daily for total course of 10 days



125
IM or IV ceftrioxone 80mg/kg once daily

If child does not improve or deteriorates within 48 hours check for complications. If none
is apparent switch to
Chloramphenicol to gentamicin (dose as above) with cloxacillin (50mg/kg every 6
hours). When child improves continue on oral cloxacillin 4 times daily for total course of
21 days.
Ampicillin/gentamicin to cloxacillin/gentamicin

Antibiotics for Severe Pneumonia
Antibiotics should be given for a total course of ten days for children with severe
pneumonia.

Give benzyl penicillin (50,000 units/kg IM or IV every 6 hours) for at least 3 days
If child improves switch to oral amoxicillin 25mg/kg twice a day for total antibiotic course
of 5 days.
If child does not improve or deteriorates within 48 hours:
Evaluate for complications of pneumonia (as for very severe pneumonia or atypical
pneumonia).
If there are no apparent complications, switch to IM or IV chloramphenicol until child
improves, then continue with oral chloramphenicol for a total course of 10 days

Antibiotic therapy for non-severe pneumonia:
Treat the child as an outpatient, give antibiotics for 3 days, (5 days in areas of high HIV
prevalence). Give amoxicillin 25mg/kg twice a day for 3 – 5 days.
Give the first dose in the clinic, and teach mother how to give the other doses at home.

Oxygen Therapy
Oxygen should be given to ALL children with very severe pneumonia, and to children
with severe pneumonia who have respiratory rates ≥ 70/minute or severe lower chest
wall indrawing. Where pulse oximetry is available, give oxygen to all children with
oxygen saturation < 90%.

Use nasal prongs (preferred), a nasal catheter, or a nasopharyngeal catheter.
Nasal prongs – oxygen flow rate of 1 – 2 litres/min (0.5 l/minute for young infants)
Nasal catheter or nasopharyngeal catheter – flow rate of 1 - 2 litre/min (0.5 l/minute for
young infants).

Continue with oxygen until signs of severe respiratory distress subside, or oxygen
saturation is stable above 90%. The nurse should check every 3 hours that nasal
catheters or prongs are in correct place and ensure no mucus is blocking them.

Supportive Care
Fever:
Above 38
0
C, give paracetamol (15mg/kg every 6 hours)
Fluids:
Ensure adequate daily fluids



126
If able to take orally encourage continued breastfeeding, or other oral fluids. If unable to
take orally (reduced level of consciousness, convulsions, severe respiratory distress)
give intravenous fluids cautiously.
Wheeze:
Assess for asthma or bronchiolitis, provide rapid-acting bronchodilator (see chapter on
asthma)
Clear airways:
Clear nasal mucous, remove any thick secretions in the throat by gentle suction.
Nutrition:
Encourage mother to continue feeding the child.

Monitoring and Follow-up
The severely ill child should be monitored every 3 hours by nurses, and twice a day by
the doctor.

Home Care Advise to the Mother for the Child with non-severe pneumonia.

For children with cough or cold, advise the mother to:
Continue feeding during the illness, and increase the frequency of feeding when the
acute phase of the illness is over. This is intended to reduce the chance of the child
developing malnutrition.
To increase the amount of fluids she gives the child during the illness. Fever, and
increased respiratory rate, together with poor appetite could lead to dehydration.
She can give safe, home made cough remedies such as warm water, honey and lemon
drink to help soothe the cough.
Avoid cough syrups

Complications
If the child has not improved over 48 hours, or has worsened, evaluate for complications
or review the diagnosis. A chest x-ray and other investigations in accordance with the
suspected complication or alternative diagnosis should be sought. Common
complications of pneumonia include pneumatocele, pneumothorax, empyema, pleural
effusion. Possible alternative diagnoses are outlined in table 1.

Bronchiolitis
Children presenting with the first attack of wheeze may have bronchiolitis, especially if
they are less than one year old. Bronchiolitis is a lower respiratory viral infection which
typically is most severe in young infants, occurs in annual epidemics and is
characterized by airways obstruction and wheezing. Secondary bacterial infection may
occur, and is common in some settings. If in addition to wheeze the child has increased
respiratory rate and/or chest indrawing their disease should be managed as for
pneumonia.
Those children presenting with recurrent wheeze and features of pneumonia/severe
pneumonia should be treated first with a rapid acting bronchodilator such as inhaled
salbutamol (by metered dose inhaler and spacer, or nebulisation) or subcutaneous
adrenaline, and reviewed after 30 minutes. If the symptoms improve (reduced wheeze,
and respiratory rate) treat as asthma. If symptoms persist, treat as pneumonia.




127
EAR INFECTIONS
The most common ear infection is otitis media. This is an infection of the middle ear.
The middle ear is considered a part of the respiratory system. It is connected to the
pharynx by the eustachian tube.
Ear infections are caused by both viruses and bacteria similar to those that cause
pneumonia, that are streptococcus pneumoniae and haemophilus influenzae.
Ear infections rarely cause death, but they cause many days of illness. Sometimes the
infection can spread from the ear to the mastoid bone leading to mastoiditis, or to the
brain leading to brain abscess or meningitis. They, (ear infections) are the main causes
of deafness in the developing countries.
The common presenting features of ear infections are, fever, ear pain and pus
discharge from the affected ear. As for pneumonia children presenting with ear problem,
should he assessed, classified and treated.
Assessing a Child Presenting with Ear Problem
The following are important in the assessment of a child presenting with an ear problem;
(I) Does the child have ear pain?
(2) Does the child have pus discharge from the ear? If yes, for how long;?
(3) If you have an otoscope find out if the ear drum is red and dull with no light
reflex. These strongly suggest ear infections
(4) Feel for tender swelling over the mastoid bone- that is behind the ear The point
of mastoid tenderness in young, infants may be above the ear-
Classifying a Child with an Ear infection
A child with an ear problem should be put into one of the following categories;
(1) Mastoiditis
(2) Acute Ear Infection
(3) Chronic Ear Infection
Mastoiditis
A child with a tender swelling behind the ear is classified as having Mastoiditis.
Such patients must be referred urgently for in patient treatment with parenteral
antibiotics similar to those used for pneumonia. Some of them may require surgery.
Acute Ear Infection
A child with pus discharge from the ear for less than two (2) weeks, or ear pain or a red
immobile ear drum has Acute Ear Infection.
The child should be given antibiotics to treat the Acute Ear- Infections. When there is
pus discharge, the treatment is wicking. This facilitates drying of the ear. Ear drops



128
should be avoided as they keep the ear moist, delay healing and do not reach the
infection.
Chronic Ear Infection
A child who has had pus discharge from the ear for more than two weeks, has Chronic
Ear Infection. This is the main cause of deafness in children. The most important and
elective treatment, is keeping the ear dry by wicking.
Bacteria that are found in the ear two weeks after onset of pus discharge are due to
secondary infections. Commonly grown are bacteria such as peudomonas, proteus and
gram negative enteric organisms. Sometimes, fungi are isolated. A chronically draining
ear will heal only if it is dry. Drying the ear by wicking is time consuming but it is the
only effective therapy. The infections do not respond to antibiotics. Do not apply
any fluid into the ear.
THROAT INFECTIONS
Throat infections are common reasons for children seeking medical attention. Sore
throat is a major complaint that accompanies common colds. The large majority are
caused by viruses. They get better in a few clays with good home care and no
additional treatment. Antibiotics are not indicated in these patients. Most children only
need a safe, soothing remedy for the sore throat.
The indications for antibiotics in sore throats are the following;
(I) Diphtheria infections (a very uncommon infection)
(2) Streptococcal pharyngitis
() Peritonsillar abscess
(4) Retropharyngeal abscess
Streptococcal pharyngitis is more common in the age group five to 15 years and rare in
the under five year olds. It is treated with antibiotics to prevent the complication of acute
rheumatic fever and the subsequent acute rheumatic heart disease.
Assessment of a child presenting with Sore Throat
The following are important in the assessment of a child with a sore throat;
(1) Is the child able to drink?
(2) Does the child have an exudate in the throat?
(3) Does the child have enlarged tender cervical lymph nodes'?
Classify the illness
Children with sore throat can be placed in three categories as follows;
(1) Throat abscess
(2) Streptococcal sore throat



129
(3) Simple viral sore throat
Throat Abscess
A child who is not able to drink at all is classified as having a Throat Abscess. Besides
this, they may present with drooling of saliva and tenderness at the angle of the jaw.
Although it is not common, children may develop abscesses behind the throat or around
the tonsils. The abscesses make it difficult for the child to swallow water. A child with
throat abscess should be referred for inpatient treatment and, if needed, to drain the
abscess. These patients should be given parenteral antibiotics such as benzylpenicillin
and chloramphenicol.
Streptococcal Sore Throat
Streptococcal sore throat (also referred to as streptococcal pharyngitis or strep throat),
is caused by Lancefield group A beta haemolytic streptococcus. A child who presents
with tender, enlarged lymph nodes in the front of the neck, AND a white exudate on the
throat is classified as having Streptococcal Sore Throat. Such patients normally have no
features suggestive of viral nasopharyngitis which include rhinorrhoea, conjunctivitis
and cough. A child with streptococcal sore throat should preferably be given
benzanthine penicillin single injection. This treatment will prevent the development of
rheumatic fever. Note that group A beta haemolytic streptococcus does not respond to
cotrimoxazole and this drug must not be used.
Simple Viral Sore Throat
The majority of sore throat are due to viruses, and get better in a few days with good
home care and no additional treatment. Most of these children only need a safe,
soothing remedy for the sore throat, to keep the throat moist. These patients should not
be given antibiotics.
PREVENTION OF ARI
Standard ARI case as given in this chapter has greatly reduced deaths in the under
fives. Prevention of pneumonia on the other hand requires reduction of the risk factors
outlined earlier. Of particular importance is reduction in early childhood undernutrition
which is estimated to be the underlying cause of mortality in about 60% of deaths in the
under fives.

Avoiding overcrowding, cooking inside the house, and smoking are also important.

Currently conjugate vaccines against H influenzae and streptococcus pneumoniae have
become available. These are either already incorporated in the childhood vaccination
programmes in the region or are soon to be included.








130
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




























131

CHAPTER 10

ASHMA IN CHILDREN

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

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

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

Learning activities

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

Definition

Asthma is a chronic inflammatory condition with reversible airway obstruction. It is
characterized by recurrent episodes of wheezing, often with cough, which respond to
treatment with bronchodilators and anti-inflammatory drugs.

The prevalence of asthma childhood in Africa ranges from 2% to 18% and seems to be
increasing.

Pathogenesis
The pathogenesis of asthma is unclear. It however has significant genetic and
environmental components. Host factors important for the development of asthma
include atopy, airway hyper responsiveness, obesity, and male sex. Environmental
factors include allergens (e. g house dust mite, pollen), viral infections (e. g rhinovirus),
and pollutants (e. g smoke) and exercise in dry cold weather.

Mechanisms of asthma

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



132
release bronchoconstrictor mediators and specific cytokines that are responsible for the
airway hyper responsiveness as well as epithelial damage and remodeling (figure 1).


Lower airway
injury




. Persistent inflammation
Aberrant . Airway hyper responsiveness
Repair . Remodeling
. Airways growth and
differentiation



ASTHMA

Figure 1. (Adapted from Nelson textbook of pediatrics, 18
th
edition)

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

Environment

. Allergens
. Infections
. Pollutants
. Microbes
. Stress




. Biological and
genetic risk
. Atopy

.



133



Assessment of an acute exacerbation of Asthma
Table 1 : Severity of Asthma Exacerbations
Mild Moderate Severe Respiratory
arrest
imminent
Breathless Walking
Can lie down
Talking infant
– softer
shorter cry;
Difficulty
feeding
Prefers sitting
At rest
Infant stops
feeding
Hunched
forward

Talks in Sentences Phrases Words
Alertness May be
agitated
Usually
agitated
Usually
agitated
Drowsy or
confused
Respiratory
rate
Increased Increased Often >
30/min

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

Accessory
muscles
and
suprasternal
retractions
Usually not Usually Usually Paradoxical
thoraco-
abdominal
movement
Wheeze Moderate,
often only end
expiratory
Loud Usually loud Absence of
wheeze
Pulse/min < 100 100 – 120 > 120 Bradycardia
Guide to normal pulse rate in children
Infants 2 – 12 months – normal rate
< 160/min
Preschool 1 – 2 years
< 120/min
School-age 2 – 8 years
< 110/min

Sa O2 % (on
air)
> 95% 91 – 95% < 90%
Hypercapnia (hypoventilation) develops more
readily in young children than in adults and
adolescents.






134





Table 2. Management of acute exacerbation of asthma
Mild to Moderate
exacerbation
Severe exacerbation Life-threatening asthma
- Salbutamol
inhalation via
spacer and mask: 2
puffs every 10
minutes to a
maximum of 10
puffs
- If good responses
then reduce the
frequency to 2-4
puffs every 2 to 4
hours.
Or
- Salbutamol
nebulisation 2.5
mg<2 years 5
mg>2 years
AND
- Start prednisolone
at beginning of
treatment 1 mg/kg
(Max 40 mg) PO
OD for 3 days

- Discharge if
improving. If poor
response after 1-2
hours admit and
manage as severe
exacerbation
Humidified oxygen by
nasal prongs or nasal
catheter (1-2 l/min)
Salbutamol inhalation or
mobilization as for
moderate exacerbation
PLUS
Inhaled ipratropium
bromide via spacer or
nebulizer 4-6 hourly
125 mcg< 1 year
250 mcg if 1-5 years
500 mcg>5 years
AND
prednisolone PO
If poor response after 1 -2
hours or vomiting, give IV
hydrocortisone 4 mg/kg
every 6 hours

If poor response after a
further 2 hours give IV
aminophylline
5 mg/kg infusion over 20
min then slow infusion at
the rate 1 mg/kg/hour
Admit to wards
Reassess every 2 hours
Admit to PICU or special
ward and treat as for severe
exacerbation.

If not improving,
Prepare for intubation and
Mechanical ventilation

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




135
Classification of Asthma Severity by Clinical Features Before Treatment

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





















136

Management of a child with chronic asthma

Patient education

Patients /Caregivers should be educated on the following:

a. Identification and avoidance of risk factors including
- indoor cooking with charcoal, wood or paraffin stoves
- parental smoking
- contact with pets




137
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.




138
References

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

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

3. Papadopoulos NG and Kalobatson A. Respiratory viruses in childhood asthma.
Curr Opin Allergy Clin Immunol, 2007; 7(1): 91-95

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

5. AL-Hajjaj MS. Bronchial asthma in developing countries: A major social
and economic burden. Annals of Thoracic Medicine, April-June 2008, vol 3, 2:39

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

7. Busse VW and Lemanske RF. Asthma. New Engl Jour of Med, February 2001,
Number 5, vol 344:350-362

8. GINA. Global strategy for asthma management and prevention 2007 report.

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

9. Zar HJ et al. Home-made spacers for bronchodilator therapy in children
With acute asthma: A randomised trial.
Lancet 1999; 354:979-982

10. Zar HJ et al. Randomized controlled trial of the efficacy of a metered dose
Inhaler with bottle spacer for bronchodilator therapy in acute lower airways
obstruction.
Arch Dis Chil, doi: 10, 1136/adc.2006.101642.

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

12. Kenya association for the prevention of tuberculosis and lung disease (KAPLD).
Consensus statement on the management of asthma in Kenya, 2005.










139
CHAPTER 11

TUBERCULOSIS IN CHILDREN

Elizabeth Maleche-Obimbo, Andrew Ndamira, Catherine Chunda

INTRODUCTION
Tuberculosis (TB) is a major cause of illness and death worldwide especially in Asia and
Africa. Globally, there were an estimated 9.2 million new cases, and 1.7 million TB -
related deaths, of which approximately 400,000 were in children, and 0.2 million in HIV
positive individuals in 2006.

In Africa, cases of TB are on the increase due to poverty, political instability,
overcrowding, malnutrition and HIV infection. Paediatric TB accounts for approximately
10 – 20% of all reported cases.

The emergence of HIV infection has grossly altered epidemiological patterns of TB.
About one third of the estimated 40 million people living with HIV worldwide are co-
infected with TB, and they have a five-fold higher mortality than in individuals with TB
alone.

Learning Objectives

By the end of this chapter, the student should be able to

1. Discuss the epidemiology of Tuberculosis (TB) in children
2. Understand the aetiology and pathophysiology of TB in children
3. Describe the clinical presentation of TB in children
4. Understand the approach to making a diagnosis of TB in a child
5. Outline the treatment of various forms of TB in children
6. Discuss the diagnostic and treatment challenges of TB in
the immuno-compromised child
7. Describe the principles of prevention of TB in children

Learning Experience
Practice taking a history in a child suspected to have TB
Assess for physical signs suggestive TB
Perform a and interpret tuberculin skin test
Participate in giving BCG to a newborn
Find out how your country manages to do contact tracing of children of parents with
sputum positive pulmonary TB

Epidemiology of tuberculosis in Children

Risk factors for TB infection in children include the following:
Young age: the younger the child is, the higher the risk of infection and disease
progression; infants are at a higher risk due to poorly developed immune system
Infants in close contact with sputum positive adults



140
Children with severe malnutrition
HIV infected children
Post-measles or post-pertussis infection
Non-immunized children (higher risk of severe tuberculous disease)
Other immuno-suppressive states such as diabetes mellitus, malignancies, steroid
therapy etc.

Other population based factors greatly influence prevalence and epidemiological
patterns of childhood TB in different geographical regions:
1. Intensity of the epidemic:
In populations where TB cases are widespread, there is an increased chance of
exposure of children in that population to infection.
2. Age structure of the population:
The younger the population, the higher the likelihood of having many children infected
with TB. (In Africa up to 50% of the population is below 18 years)
3. Delay in diagnosis and treatment of adult index cases
This may be due to
i) Delayed presentation of sick adults to health facilities
ii) Lack of diagnostic tools:
iii) Poor contact tracing and screening of child household contacts of these infected
adults
iv) Poor health infrastructure contributes to all the factors above.

Children are more likely to progress to active TB disease than adults, with infants and
children under 5 years at greatest risk. Those who do not develop active TB disease are
described as having latent TB. The likelihood of developing disease is highest shortly
after exposure (6 – 8 weeks) and decreases with time.

Aetiology and Pathophysiology of Tuberculosis
TB is caused by Mycobacterium tuberculosis, an obligate aerobic organism that is
highly sensitive to light (direct sunlight kills bacilli in 5 minutes) and heat (bacilli die
within 20 minutes at 60°C) but highly resistant to dry conditions (bacilli can survive for
weeks and later cause infections as dust particles).

Other non-tuberculous Mycobacteria may also cause disease, notably M. bovis, M.
avium and M. africanum; these are described as atypical mycobacterial infections.

Routes of infection
The bacilli may enter the human body by any of the following routes:
Inhalation
Ingestion
Inoculation
Inhalation of bacilli through the respiratory tract is by far the most common portal of
entry (over 98% of cases); inhaled bacilli settle in the lower respiratory tract.
Local infection at the portal of entry is usually followed by spread to regional lymph
nodes (primary complex). In most children, this primary infection remains quiescent but
may result in progression of disease in any of the following ways:




141
Within the lung: multiplication of bacilli initially within alveoli and alveolar ducts before
spreading to the lung parenchyma and pleura to cause tuberculous pneumonia,
pleurisy, and in older children, pleural effusion and cavitation
hilar lymph node inflammation and enlargement, leading to compression of bronchi
which leads to lobar or segmental collapse (atelectasis)
tonsillar infection: spread to cervical lymph nodes
haematogenous (and lymphatic) spread, leading to military TB, involving the lung,
pericardium, meninges, abdomen, bone and joint
Enlarged focus (coin shadow).

Development of any of the above lesions largely depends on immune status of the
individual child as well as BCG vaccination status.

The table below shows the approximate time frame within which each of the
pathological lesions develops:

Stage Duration Features

1 3-8 weeks Primary complex, Tuberculin positivity

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

3 3-4 months TB pleurisy/pneumonia

4 Up to 3 yrs Bone & Joint

5 Up to 12 yrs Genitourinary

CLINICAL PRESENTATION OF TUBERCULOSIS
Most children with symptomatic TB will present with the following common general
symptoms: chronic cough, lasting more than 21 days, persistent fever and/or night
sweats (>14 days) and poor weight gain or loss of weight.

In addition to the general symptoms described above, depending on the site of the
active TB infection, the child may develop symptoms and signs specific to the site of the
active infection. These clinical features are described below:

Pulmonary TB
This is the commonest form of TB occurring in children. There excessive sweating,
tachypnoea, respiratory distress, nausea and vomiting. Younger children may present
with wheezing due to bronchial obstruction by enlarged hilar lymph nodes (primary
complex). Even with more than one lobe involvement in young children respiratory signs
may be absent. Older children and adolescents may present with similar disease to



142
adults with productive cough; sputum may be purulent or blood stained (haemoptysis)
and there may be signs of apical lobar consolidation and in advanced disease,
cavitation.
Pleural effusion
This tends to occur in older children. They presents with progressive breathlessness
(dyspnoea), chest pain, tracheal shift away from affected side, stony dull percussion
note, and may have a pleural rub (in early stages) and reduced breath sounds over the
affected lung. They may or may not have cough.

Lymph Node Disease
Presents with progressive painless enlargement of one group of lymph nodes. Most
commonly involved areas are cervical, submandibular, tonsillar and supraclavicular
lymph nodes. The nodes are enlarged, discrete (but may be matted together), firm,
non-tender, and fixed to surrounding structures. Eventually fistula formation may
develop, discharging caseous material, which is pathognomonic of TB lymphadenitis.

Abdominal TB
Tuberculous infection in the abdomen may present with progressive abdominal swelling
and abdominal pain associated with persistent fever and weight loss. Examination may
reveal abdominal distension with ascites, abdominal mass (enlarged lymph nodes),
enlarged liver and/or spleen. Progressive intestinal obstruction by enlarged lymph
nodes may manifest as constipation with vomiting, and abdominal distension.
Commonly involved tissues include the jejunum, ileum, Payer’s patches and appendix.
Generalized peritonitis may occur, though not common.

TB Meningitis
The clinical presentation of TB meningitis can be described in three stages as follows:
Stage I: Child presents with non-specific symptoms and signs of persistent fever,
headache, irritability and drowsiness (1-2 weeks).
Stage II: Progression to more specific symptoms and signs of meningeal irritation –
neck stiffness, positive Kerning’s sign, positive Brudzinski sign, convulsions, hypertonia,
vomiting, cranial nerve palsies and focal neurological signs.
Stage III: Child develops features of severe neurological disease including coma,
hemiplegia, decerebrate or decorticate posturing and abnormal vital signs.
Tuberculous meningitis may be differentiated from pyogenic meningitis due to the
insidious onset of symptoms (over weeks) and long history of ill health, as compared to
the acute onset (over days) of pyogenic meningitis

Tuberculoma
Tuberculomas present with features of space occupying lesions in accordance with their
location within the brain. Accompanying symptoms include headache, persistent fever,
weight loss or poor weight gain. Parietal lesions will cause paraparesis or hemiparesis
and progress to full paraplegia or hemiplegia. Children may in addition develop features
of raised intra-cranial pressure such as vomiting and diplopia.

Osteo-articular TB
This is caused by haematogenous spread of TB bacilli, initially infecting the metaphyses
of weight-bearing bones and joints (vertebrae, knee, hip, elbow and ankle), and may



143
manifest several months to years after the primary TB infection. The child presents with
initially mild pain, swelling at the site, with minimal or no tenderness, refusal to use the
limb, associated persistent low-grade fever and poor weight gain.
TB of the vertebra (Pott’s disease) presents initially with mild back pain which slowly
gets worse, abnormal posturing and reluctance to walk, progressing to inability to walk.
Examination may reveal rigidity of spine, minimal or no tenderness and abnormal
curvature of spine; in advanced stages, collapse of the vertebral body may lead to
formation of a gibbus (pathognomonic of TB spine), and to spinal compression with
resultant loss of motor function of the lower limbs and loss of bladder and anal sphincter
control.

Disseminated Disease (Miliary TB, TB Septicaemia)
This is caused by haematogenous spread of TB bacilli to multiple organs of the body; it
is usually associated with miliary lesions in the lungs, followed by miliary seeding of
various body organs (most numerous in liver, spleen and bone marrow). It is more
common in infants and severely immunosuppressed individuals (HIV infected and
severely malnourished children), and usually presents as an early complication of
primary disease (within 2-6 months of primary infection). Onset is usually insidious, with
persistent fever, weight loss, malaise, anorexia, and features of pneumonia and
abdominal involvement plus, with or without meningeal, bone marrow or urogenital
involvement.

DIAGNOSIS OF TUBERCULOSIS IN CHILDREN
The gold standard for diagnosis of TB is the identification of Mycobacterium tuberculosis
in body specimens, by microscopic examination, confirmed by positive culture of the
bacillus.

Specimens may be obtained from suspected site of infection, and include sputum
(pulmonary TB), pleural aspirate (pleural effusion), lymph node aspirate or biopsy (TB
lymphadenitis), cerebro-spinal fluid (TB meningitis), ascitic tap or fine needle aspirate
(FNA) from abdominal mass (abdominal TB), joint aspirate (TB arthritis) etc.

Challenges to diagnosis: Children, especially infants, malnourished and HIV infected
children tend to manifest with pauci-bacillary disease, and TB bacilli may not be
identified from body specimens even in the presence of active TB disease. Secondly,
the majority of affected children (under 8 years) are unable to expectorate , and
therefore confirmation of diagnosis of PTB, the most common form of TB in children
through microbiologic confirmation is not possible. Thirdly, in resource-poor settings,
many health facilities diagnostic tests may not be available.

In situations where one is unable to make a microbiologic confirmation of TB infection,
the World Health Organization has developed the following approach to clinical
diagnosis of TB in children.




144
These four criteria are defined more explicitly below:

1. Chronic symptoms suggestive of TB
Chronic cough: An unremitting cough that is not improving and has been present for
more than 14 days
Unexplained fever: Fever continuing for > 14 days, after common causes such as
malaria or pneumonia have been excluded
Unexplained weight loss or failure to thrive: As reported by parent/guardian or older
child, take weight of child, examine child’s growth chart.
History of exposure to an adult with probable or definite PTB

2. Physical signs highly suggestive of TB
a. Pulmonary TB – there are no specific clinical features that differentiate
pulmonary TB from other forms of pneumonia or pulmonary disease

b. Extra pulmonary TB
Physical signs highly suggestive of extra pulmonary TB include:
non-painful enlarged cervical lymphadenopathy with fistula (abscess) formation
Gibbus, (deformity of spine resulting from vertebral TB) especially of recent onset.
Physical signs requiring investigation to exclude or support diagnosis of extra
pulmonary TB
Meningitis with a sub-acute onset (developing over several days to weeks), not
responding to standard anti-meningitic antibiotic treatment.
Pleural effusion, one sided.
Distended abdomen with ascites with or without palpable lumps.
Non-painful enlarged lymph nodes without fistula (abscess) formation
Non-painful swelling or deformity of bone or joint.

In addition, documented weight loss or failure to gain weight, especially in child with
adequate nutritional intake, is a good indicator of chronic disease in children, of which
TB may be the cause.
Investigations relevant to rule out or support diagnosis of extra-pulmonary TB
Site of Suspected TB Infection Practical approach to diagnosis
Peripheral lymph nodes Lymph node biopsy or fine needle aspiration
Miliary TB (disseminated) Chest X-ray and lumbar puncture
TB meningitis Lumbar puncture (CT scan where available)
Pleural effusion Chest Xray, pleural tap
Abdominal TB Abdominal ultrasound, ascitic tap
Osteo-articular X-ray of bone/joint, joint tap or synovial
biopsy
Pericardial TB Ultrasound, pericardial tap
Box 1: Key features suggestive of TB
The presence of three or more of the following should strongly suggest a diagnosis
of TB
Chronic symptoms suggestive of TB
Physical signs highly suggestive of TB
A positive tuberculin skin test
Chest X-ray suggestive of TB



145

All specimens should be subjected to microscopy (acid fast bacilli stains and white cell
counts) and mycobacterial cultures. Biopsy specimens should also be subjected to
histology. CSF, pleural, ascitic, and pericardial aspirates should also be subjected to
biochemical analysis (protein and glucose concentrations). Laboratory tests are
discussed in greater detail below.

3. A positive tuberculin skin test (TST)
This is an indication that the child has been infected with the Mycobacterium
tuberculosis. Tuberculin purified protein derivative antigen is injected intradermal,
and an induration appearing at the site of injection within 3 days indicates that the
child’s immune system has been sensitized to M.TB (therefore indicates previous
infection with the bacillus). Immunocompetent children react more vigorously, immuno-
compromised children (HIV, severe malnutrition, or very severe forms of TB disease
such as military or TB meningitis) may have blunted or absent reaction even in the
presence of active TB infection. Therefore the interpretation of the TST test is as
follows:

High-risk children – HIV infected, severely malnourished children
Positive TST = induration of 5mm or more.
Negative TST = no induration, or induration <5mm

All other children
Positive TST = induration of 10mm or more
Negative TST = no induration, or induration <10mm

(It is important to appreciate that in the high risk children, a negative TST reaction may
be a false negative, i.e. does not rule out the presence of M.TB infection in this group of
children)

4. Chest X-ray suggestive of TB
The following radiological pictures are suggestive of TB in children

Persistent opacification in the lung with enlarged hilar or subcarinal lymph nodes.
Miliary pattern of opacification in both lungs
Large pleural effusions*
Apical infiltrates with or without cavity formation*
Enlarged hilar adenopathy with lobar collapse*

*These radiological pictures are seen mainly in older children and adolescents.

Bacteriologic Confirmation
Obtaining specimens
Sputum may be obtained through expectoration by child, sputum induction, or removal
of swallowed sputum by aspiration of gastric contents early in the morning.






146
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)




147


Recommended treatment regimens
Anti-TB treatment is given in two phases:
1) Intensive phase
The purpose of the intensive phase is to rapidly eliminate most of the organisms and to
prevent emergence of drug resistance; this phase, therefore uses more drugs than the
continuation phase.

2) Continuation phase
This phase is intended to eradicate dormant bacilli and thus uses fewer drugs.

Table 3: Summary of Recommended TB Treatment Regimens:


Diagnosti
c
Category

TB Cases
Regimen
Intensive
Phase
Continuation
Phase

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




2RHZE



4RH

I b

TB Meningitis

2RHZS*

4RH


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


2RHZES/
1RHZE

5RH


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


2RHZ

4RH
IV Multi-drug resistant (MDR) TB Refer to TB specialist centre





148
* Note that in treatment of TB meningitis, streptomycin replaces ethambutol since
the latter does not cross the blood – brain barrier

MANAGEMENT OF TB IN THE HIV INFECTED CHILD

The diagnosis and treatment of TB in the HIV infected child has several challenges
which shall be outlined in this section.

Diagnosis
Chronic symptoms
HIV infected children frequently have recurrent or persistent HIV-related illnesses and
consequently the chronic symptoms suggestive of TB (chronic cough, persistent fever,
weight loss or poor weight gain) are frequently present in the HIV infected child as part
of HIV disease itself, and could suggest TB or many other underlying HIV-related
diseases.

Physical sign:
Due to their deteriorating immunity, HIV infected children with pneumonia or meningitis
frequently respond poorly to antibiotic therapy, as such, this sign may suggest TB, but
may also suggest many other pathogenic infections.

Tuberculin Skin Test (TST)
Due to poor cell mediated immunity, HIV infected children with advancing disease may
have poor immune response to tuberculin antigen, therefore have negative TST test
even in the presence of active TB infection.

Suggestive Radiology: HIV infected children frequently present with atypical
radiological pictures even in the presence of PTB, such as more widespread disease,
absence of lung opacities due to their inability to mount a good inflammatory response
to existing micro-organisms.

Microbiologic Confirmation of TB infection
HIV infected children may have pauci-bacillary disease, therefore making it difficult to
identify mycobacteria from their various body specimens.

Because of the above reasons, TB may be over-diagnosed in these children due to high
frequency of symptoms and signs suggestive of TB that they may present with.
However TB may also be missed due to atypical presentation, anergic TST and
negative bacteriologic tests.

In approaching diagnosis of TB in an HIV infected child, one should use the same
approach as outlined above – microbiologic diagnosis, and /or clinical diagnosis by
evaluating for suggestive symptoms, signs, radiology and positive TST. One must have
a higher index of suspicion in these children.

Treatment of Tuberculosis in the HIV infected Child
Several factors must be considering when planning treatment of TB in the HIV infected
child as follows:



149

Child will require anti-TB drugs as well as antiretroviral drugs (6 drugs), consideration to
timing of initiation of both therapies, and selection of drugs with consideration of drug
interactions.
Consideration of adverse effects of drugs
Severely immuno-suppressed children may have severe forms of TB slower response
to anti-TB therapy, therefore may require more aggressive therapy

Timing of Initiation of Therapy

Scenario A: TB develops in child not yet on ART

In this scenario, anti-TB therapy should be initiated immediately the diagnosis of TB is
made, in accordance with treatment guidelines as outlined earlier in this chapter.
Antiretroviral therapy should be initiated soon after, within the next 2-8 weeks.
This allows for initial containment of TB bacillary load as well as identification and
management of any early adverse reactions during the first weeks of anti-TB therapy
before introducing the ARV drugs.

Scenario B: If child develops TB while on ART

In this scenario, one must evaluate as follows:
1. Is this TB that was incubating at time of ART initiation, or immune reconstitution
inflammatory syndrome (IRIS)? TB is likely if:
TB develops < 6mths after ART initiation
No other evidence of CD4 decline or clinical progression
(Viral load remains controlled – if assay available)
In this scenario, give standard anti-TB therapy, however, care should be taken to
ensure that ARV drugs used are compatible with the anti-TB drugs.
2. Is this ARV treatment failure? This is likely if:
TB develops > 6mths after ART initiation
Evidence of CD4 decline or clinical progression (other stage 3-4 defining illness)
(Viral load increase - where assay available)
In this scenario, anti-TB therapy should be initiated, however ARV therapy should be re-
evaluated by HIV specialist to identify reason for failure of ARV regimen, and plan how
to proceed regarding the patients ART (meanwhile the patient should continue with their
existing ART regimen alongside the anti-TB therapy)

Selection of antiretroviral therapy regimen
Rifampicin, an enzyme inducer, may induce rapid metabolism of non-nucleoside
reverse transcriptase inhibitors (most affected is nevirapine) and most protease
inhibitors (most affected is lopinavir). In general therefore, one should avoid combining
rifampicin with nevirapine or with lopinavir. If these are the only drugs available,
possible approaches include:

increase the dose of nevirapine by 30% during the period of anti-TB therapy (monitor
closely for NVP adverse effects), or boost lopinavir with additional ritonavir to achieve
LPV: r in 1:1.



150

Acceptable ART regimens for use with rifampicin:

Two NRTI drugs + efavirenz (age above 3 years)
Two NRTI drugs + ritonavir boosted lopinavir, with supplemental ritonavir to provide
LPV: r at ratio of 1:1
Two NRTI drugs + nevirapine (age below 3 years where LPV/r + r option not feasible)

Vitamin B6 supplementation: HIV infected children frequently are malnourished,
and care should be taken to give them concurrent vitamin B 10mg once daily during the
period they are on isoniazid, to reduce risk of neurotoxic adverse effects of INH.

Prevention of Tuberculosis in Children
Diagnosis of paediatric TB is difficult and treatment of diagnosed cases involves
meticulous calculation of optimum doses and several months of follow-up. Treatment
default and poor compliance are therefore major challenges in the treatment and control
of TB.

Prevention of infection is therefore the most realistic way to control the TB epidemic and
should form the basis of all TB control programmes. Preventive measures take different
forms:

1. Prevention of infection:
Prevent contact with individuals likely to have sputum-positive pulmonary TB.
Prompt diagnosis and treatment of suspected cases of pulmonary TB using appropriate
combination therapy.
Contact tracing and treatment.

2. Prevention of drug resistance:
Promotion of the DOTS policy to avoid default and non-compliance
Improve surveillance to detect multi-drug resistant (MDR) TB
Ensure proper dosage calculation based on patient’s body weight

3. Reduce vulnerability of children to developing TB:
Improve nutritional status of children
BCG vaccination of all infants at birth (protects children from severe forms of TB)
Isoniazid prophylactic therapy to children exposed to open TB especially HIV infected
children, and children under five years.
Prevention of mother-to-child HIV infection

4. Health education:
Ensure that all people (especially community leaders) understand
The epidemiological importance of TB
The common symptoms and signs of TB
The importance of completion of therapy






151

REFERENCES


Global tuberculosis control - surveillance, planning, financing. WHO Report 2008.
Geneva, World Health Organization.
http://www.who.int/tb/publications/global_report/2008.

Guidance for national tuberculosis programmes on the management of tuberculosis in
children. WHO 2006. Geneva, World Health Organization. WHO/HTM/TB/2006.371.

Jeena PM, Pillay P, Pillay T and Coovadia HM. Impact of HIV-1 co-infection on
presentation and hospital related mortality in children with culture proved pulmonary
tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis 2002;6:672-678.

Mukadi YD, Wiktor SZ, Coulibaly IM et al Impact of HIV infection on the development
and clinical presentation and outcome of tuberculosis among children in Cote d’Ivoire.
AIDS 1997;11:1151-1158.

La Porte CJ, Colbers EP, Bertz R, Voncken DS, Wikstrom K, Boeree MJ, Koopmans
PP, Hekster YA, Burger DM. Pharmacokinetics of adjusted-dose lopinavir-ritonavir
combined with rifampin in healthy volunteers. Antimicrob Agents Chemother. 2004
May;48(5):1553-60.

Madhi SA, Huebner RE, Doedens L, Aduc T, Wesley D, and Cooper PA. HIV-1 co-
infection in children hospitalised with tuberculosis in South Africa. Int J Tuberc Lung Dis
2000:448-454.

Niemi M, Backman JT, Fromm MF, Neuvonen PJ, Kivisto KT. Pharmacokinetic
interactions with rifampicin: clinical relevance. Clin Pharmacokinet. 2003;42(9):819-50.





152
CHAPTER 12

MALARIA IN CHILDREN

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

INTRODUCTION
It has been estimated that 90% of the African population live in malarious zones and
malaria is a direct cause of approximately 12% of all deaths of African children below
five years of age. Malaria is, therefore a threat to child survival and development. It is a
major cause of foetal loss and low birth-weight (LBW) particularly in primiparous
mothers. The risk of severe malaria is greatest during pregnancy, early puerperium,
early childhood and in individuals where malaria coexists with other infections, stress or
chronic diseases and in individuals with little or no immunity to malaria.

Over the last 10 years, management of malaria has been bogged down by high
resistance of P. Falciparum to choroquine, sulphadoxine-pyrimethamine. Currently,
artemesinin containing combinations are recommended at Primary Health Care level.

Protein energy malnutrition (PEM), anaemia and malaria often coexist and aggravate
each other. The effect of malaria, starting from pregnancy (anaemia, LBW and
abortion), infancy (anaemia and death) and young children can result in:-
Sapping the energy and growth in children
Poor education and stunted growth in children
Low work output
Reduced or slow economic development

Therefore, control of malaria as an integral part of Primary Health Care (PHC) is very
important for a health community

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

Explain the transmission of malaria
Explain the epidemiology of malaria and measure the extent of the problem in your
community
Explain the pathophysiology of malaria in children including:-
- The clinical features of uncomplicated and complicated malaria.
- Diagnose uncomplicated and complicated malaria

Enumerate complications of malaria in children
Treat uncomplicated and severe attacks of malaria
Identify and treat drug resistant malaria
List methods of control and prevention of malaria






153

LEARNING ACTIVITIES
During your paediatric rotation, make a clinical diagnosis of malaria and confirm it by
laboratory investigations
During your paediatric rotation, note the number of children admitted with malaria and
the major complications.
During your community assignment, estimate the frequency of malaria in schools based
on the frequency of anemia, hepato-splenomegaly and positive blood smear;
During your community assignment, determine the availability and common use of
antimalarial drugs.

AETIOLOGY AND TRANSMISSION OF MALARIA
Malaria is caused by protozoa of the genus plasmodium. The species which affect man
are P.falciparum, P.vivax, P.malariae and P.ovale. P. falciparum is the most important
cause of malaria in human beings. Transmission is from man to man by the following
ways:-
The bite of an infected female anopheles mosquito, commonly Anopheles gambiae and
Anopheles fenestus
Transplacental infection from an infected mother.
Through blood transfusion

Factors perpetuating malaria transmission
i) A reservoir of parasites in human population from which the mosquitoes can
pick the infection in form of Gametocytes.
ii) Presence of mosquito breeding sties. Stagnant water bodies such as in pits,
puddles, fishponds, edges of swamps and creeks.
iii) Suitable climatic conditions such as the mosquito to survive and the parasite
to develop within the mosquito. Warm moist conditions with relative humidity
of 60% and mean daily temperature of 18
o
C.

Methods Used to estimate Prevalence of Malaria:

The following are methods used to estimate the prevalence of malaria in a community:-

1. Spleen Rate
This method estimates the proportion of children in the age group two to ten
years who have splenomegaly (see table 1 below)

Table 1: WHO Classification of Malaria Endemicity
Malarial Endemicity Spleen Rate
(in children 2-10 yrs of age)
Spleen Rate
(in adults)
Hypoendemic 0-10%
Mesoendemic 11-50%
Hyperendemic >50% >25%
Holoendemic 75% Low

The low adult spleen rates in holoendemic areas indicate considerable immunity
acquired by intense exposure to perennial transmission.



154

2. Parasite Rate
This is a proportion of the population in which malaria parasites are found using
blood films.

3. Parasite Count
This can be reported as parasites against leucocyte count for exact amount of
blood related to a count. (parasites/µl)

PATHOGENESIS OF MALARIA
Haemolysis and tissue ischaemia account for the majority of pathophysiological
changes. The higher the parasite could worsen the prognosis. Release of interleukins
from infected erythrocytes is responsible for clinical features such as fever.

Infected erythrocytes become sticky and are coated with fibrin which causes
agglutination and obstruction in small vessels, this leading to local hypoxia. In addition,
the following disturbances may occur:-

1. Anaemia
More severe with P.Falciparum because it invades red blood cells of all ages
and frequently produces a high level of parasitaemia;

Mechanisms of anaemia in malaria infection are:-
direct lysis of red blood cells caused by dysfunction of Na+ Pump
splenic removal of parasitized red blood cells;
autoimmune destruction of infected and non infected coated erythrocytes;
reduced incorporation of iron into bone;
impaired erythropoiesis due to direct bone marrow suppression form malarial toxin;
increased intramedullary destruction of red blood cell precursors and erythrocyte
maturation arrest from folic acid and PABA deficiencies.

2. Hypoglycaemia
Occurs due to depleted glycogen stores and competition for serum glucose by the
parasite. Reduced food intake and the increased secretion of insulin in patients treated
with quinine also contribute to hypoglycemia. There may also be use of traditional
herbs that contribute to protracted hypoglycaemia.

3. Thrombocytopenia
Can occur due to splenic sequestration and bone marrow depression

4. Hypergammaglobulinaemia, hypocholesterolaemia, hyperbilirubinaemia and
raised transaminases do occur frequently due to fever and liver dysfunction.

5 Hepatomegaly is due to congestion from parasitized cells in sinusoids, and
centrilobular veins and due swollen parenchymal and Kupffer cells;

6. Hyperkalemia and hyponatremia are seen in acute attacks of malaria. They
are due to increased destruction of red blood cells and intravascular volume



155
expansion occurring as a compensatory response to the vasodilatation
caused by malaria toxins;

7. Acidosis can occur due to increased lactate and pyruvate production as the
parasites use glucose;
Splenomegaly occurs due to hyperplasia of reticuloendothelial system and
vascular congestion. Tropical splenomegaly syndrome (TSS) occurs due to
an abnormal immune response to persistent malarial antigen stimulation in
an endemic region;

9. In the brain parasitized red blood cells are preferentially sequestrated in deep
capillaries causing clogging and subsequent ischemic changes, congestion,
oedema and central nervous system manifestations.

Pulmonary oedema may complicate cerebral malaria, severe anaemia, high
parasitaemia or be caused by fluid overload during management.

CLINICAL FEATURES
The clinical picture of malaria in children depends on child's age and immunity.
The non-immune infants and children who contract malaria for the first time also have a
variable clinical picture. They may present with restlessness, drowsiness, listlessness
or refusal to feed. They may also have headache, nausea and pallor. A clear cut cold
stage and rigor are uncommon. Vomiting can be severe causing dehydration and
electrolyte imbalance. Fever is invariable, often continuous although it may also be
irregular. Convulsions often occur. Signs of cerebral malaria include fever, impaired or
loss of consciousness, convulsions, with normal cerebral-spinal findings.

DIAGNOSIS OF MALARIA
Definite diagnosis of malaria is made by establishing the presence of malaria parasites
in the blood by examining a blood smear. However, due to delays in blood testing in
developing countries, malaria should be suspected in all cases of fever in endemic
areas. Proper history taking and physical examination is mandatory to differentiate
malaria from other febrile conditions such as urinary tract infection, meningitis, tonsillitis,
viral infection, etc. Some investigations (other than a blood smear) may be necessary
in order to exclude the coexistence of other infections. A malaria negative blood slide
does not exclude malaria infection. Diagnosis of malaria may also be made by detection
of antibodies in the blood using the rapid diagnostic tests (RDT's). Since malarial
antibodies persist in the blood of the patient after the infection, these tests are therefore
only useful for surveys or research work and in subjects in whom parasites are difficult
to find.

Counting Malaria Parasites in a blood film using parasite per micro litre method
Counting malaria parasites reflects the degree of parasitaemia, which in turn is related
to prognosis.

A thick blood film is made and examined under the oil objective of a microscope. Two
hundred leucocytes are counted using a tally counter. At the same time using a
separate tally counter, the number of malaria parasites in the fields is counted. When



156
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 > 39
o
rectally)
Severe anaemia (packed cell volume of less than 20%);
Algid malaria which presents as peripheral vascular collapse due to adrenal failure; may
have concurrent gram negative septicaemia
Black water fever (massive intravascular haemolysis leading to haemoglobinuria)
Acute Renal Failure (usually acute tubular necrosis due to presence of sequestrated
infected red blood cells in the renal tubules and hypovolaemia).
Disseminated intravascular coagulopathy (DIC) due to consumptive coagulopathy;
Metabolic acidosis resulting from anaerobic tissue respiration, dehydration and renal
failure;
Hypoglycaemia due to starvation from anorexia, vomiting, and use of quinine and also
due to competition for serum glucose by malaria parasites.
Pulmonary Oedema due to sequestration of parasitized red blood cells in the lungs and
from heart failure and IV fluid overload.

B. Vivax, Quartan and Ovale Malaria
Complications of acute attacks of vivax, quartan or ovale malaria are relatively
uncommon but the infection may undermine the general condition of the growing child
and aggravate other intercurrent diseases. High temperature seldom persists. Cerebral
and intestinal symptoms are rare, but nephrotic syndrome is a complication often seen
with chronic plasmodium malariae.



157

Vivax and Ovale malaria may be associated with relapses. This is due to some of the
circulating parasites (merozoites) returning to the liver and remaining dormant until a
later date when the immunity wanes and re-seeding of the blood occurs.

TREATMENT OF MALARIA
A. Treatment of malaria in infants and children poses special problems because of
the following reasons:-
Acute attacks of malaria are more severe than in adults;
Vomiting is common and reduces the treatment options as oral medication may not be
possible;
Cerebral malaria is more common than in adults;
Gastrointestinal complication presenting with diarrhea and vomiting can cause severe
dehydration;
Anaemia may be severe enough to require blood transfusion;
Compliance with medications can be poor because children cannot be made to
understand its importance, therefore, parent' health education and their cooperation re
absolutely vital in the treatment of malaria.

Except in case of drug-resistance, quick acting schizonticides are more preferable than
slow acting ones in the treatment of acute attacks of malaria. Treatment of simple
versus complicated infection will be discussed separately thus:-

Guidelines for treatment of uncomplicated malaria

The recommended first line treatment for malaria treatment is Artemesinin – based
combination therapies (ACT). There are different ACT formulations in the market.

Artemether (20mg)/Lumefantrine (120mg) is one such combination recommended by
the World Health Organization (WHO). For dosage, see table below:


Wt Category (kg) Age Day 1 Day 2 Day 3
5-14 4mo-
3years
1tab, 12
hourly
1tab, 12
hourly
1tab, 12
hourly
15-24 3yrs-7yrs 2tabs, 12
hourly
2tabs, 12
hourly
2tabs, 12
hourly
25-34 7yrs-12yrs 3tabs, 12
hourly
3tabs, 12
hourly
3tabs, 12
hourly
>34 ≥ 12yrs 4tabs hourly 4tabs, 12
hourly
4tabs, 12
hourly

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



158
A combination of amodiaquine and sulfadoxine/pyrimethamine is also used in some
areas.

Second line antimalarial treatment
Oral quinine is the recommended second line malaria drug. Indications or reasons for
choosing second line antimalarial drug include:
Failed first line antimalarial treatment

ii) First line drug contraindicated in the particular patient.
in infants <3 months of age or whose weight is <5kg

Treatment of complicated malaria (severe)
P. Falciparum infection can cause a medical emergency of the first order especially
when over 5% of the red blood cells are infected. These patients may present with
convulsions, stupor, copious vomiting and diarrhea, anaemia, acute abdominal crisis or
acute renal failure. For these types of patients speed is absolutely vital in order to save
them. Therefore, quinine which has a more rapid schizonticidal action than other
schizonticidal drugs is the drug of first choice. It is given intravenously at a dose of
20mg/kg of body weight for first dose diluted in 10mls/kg of 0.45% sodium chloride in
5% glucose and then 10mg per kg every eight hours until the patient is well enough to
take oral medications. Quinine intravenous infusion should be run slowly over 4 hours
to avoid cardio-vascular complications including cardiac arrest. Intravenous quinine is
associated with hypoglycaemia due to stimulation of insulin and should be given in a
dextrose solution.

Oral quinine 10mg kg every eight hours should then be administered to make up to
seven days of quinine therapy. In addition to the correction of anaemia, hypoglycaemia,
water and electrolyte imbalance if they exist should be corrected.

Supportive treatment in severe malaria
Hyperpyrexia (axillary temp ≥ 38.5
o
C)
Paracetamol 15mg/kg every 6-8hours
Tepid sponging
Dress lightly
Severe anaemia (Hb ≤ 5g/dl)
Blood transfusion 20mls/kg of whole blood or 10mls/kg of packed red blood cells
Congestive heart failure
Oxygen
Iv furosemide 1.0 -1.5 mg/kg
Correct severe anaemia (blood transfusions)
Dehydration & Electrolyte imbalance from vomiting, anorexia
IV Normal saline, Ringer's lactate
or Darrow's 1/2 strength Darrow's solution. 20mls/kg over 30 min.
Total amount of iv fluid and rate of infusion depends on the level of dehydration.

OR
If facilities for iv drip are not available, give deep iv quinine 10mgs salt/kg before
referral.



159
For intramuscular quinine, the quinine should be diluted in normal saline to
concentration of 100mg salt/ml. The intramuscular site should be in the antero lateral
thigh region.

OR
Intramuscular Artesunate 2.4mg/kg loading dose, followed by iv. 1.2mg/kg at 12 and 24
hours, then 1.2mg/kg daily or 6 days.

OR
Intramuscular
Artemether 3.2mg/kg (loading dose) followed by 1.6 mg/kg daily for 6 days. When the
patient is able to swallow, the daily dose can be given orally.

Artemesinin Suppositories: 40mg/kg, loading dose intra rectally, then 20mg/kg given 24,
48, & 72 hours later, followed by oral first line drug.

MALARIA DRUG RESISTANCE

Malaria drug resistance is defined as the ability of a strain of a malaria parasite to
survive and multiply inspite of an antimalarial drug in usual or even higher than usual
does. Drug resistance (R) is divided into three types depending on its severity viz:-

RI drug resistance with recrudescence. Parasites reappear in blood within
fourteen days following initial clearing of symptoms and parasites;

RII drug resistance with low parasitaemia which never clear completely;

RIII drug resistance with persistently high parasitaemia for twenty-eight days.

There should be no re-infection and the drug given should be well tolerated. Clinically,
drug resistance should be suspected when there is:-


Persistence of fever and no improvement forty-eight hours after starting drug treatment;
Poor laboratory response to the antimalarial treatment when blood test is done daily as
treatment proceeds.

MALARIA CONTROL
The World Health Organization (WHO) has defined levels of malaria control
interventions (Tactical variants) with ultimate aim of malaria eradication. Malaria control
is also part of Primary Health Care since 1978.

Tactical Variant I
Aims at reducing and preventing both mortality and morbidity due to malaria using
antimalarial drugs. Essential drug programme should therefore be encouraged for
efficient distribution of antimalarial drugs to the acutely ill patients.





160

Tactical Variant II
Aims at reducing and preventing both mortality and morbidity due to malaria. This calls
for antimalarial drugs for both curative and chemo prophylaxes for the high risk
vulnerable groups with include:
The non-immune immigrants;
The pregnant women
Under-fives with special problems, e.g., sickle cell anaemia

Tactical Variant III
This objective is to prevent mortality and reduce malaria prevalence and morbidity. It
adds the reduction of man-vector contact to tactical variant II.

Tactical Variant IV
Aims at achieving countrywide malaria control. It is concerned with surveillance after
malaria control has been achieved and ensures that resurgence does not occur. The
long term aim is eradication of malaria.

Drugs Used for Chemoprophylaxis
The drugs used for prophylaxis against malaria include:
Proguanil, chloroquine, sulphadoxine-pyrimethamine, mefloquine.
Resistance to chloroquine is very high and therefore this drug can no longer be used
alone as a casual prophylaxis.

Sulphadoxine- pyrimethamine is used as chemoprophylaxis during pregnancy (second
and third trimester only) and is known to have reduced the incidence of low birth weight.

Problems Associate with Chemoprophylaxis
1. Due to drug resistance it is not certain which prophylactic (single or combination) is
best for non immune immigrants and pregnant women whose choices are rather limited;

2. For under-fives, chloroquine chemoprophylaxis is not advised except in those with
special problems, e.g. Sickle cell anaemia because:
It is not easy to achieve continuous suppression in a significant proportion of those
children.
It might interfere with their development of acquired protective immunity;
It may accelerate the development of drug resistance;
It uses scarce resources that could have been better used for better treatment

Problems of Vector Control
Resistance of vector to most insecticides
Technical problems to cover all the endemic areas
Expensive mosquito nets and repellants
A large mosquito breeding habitat (swamps)
Human activity interfering with environment






161
IMMUNITY AND VACCINE DEVELOPMENT
Immunity to malaria parasites can be natural or acquired.

Natural Immunity
Genetic Immunity is seen in:
Some black communities due to some form of natural selection, e.g., Duffy blood
groups and P.vivax infection.
Population with long exposure to P.Falciparum is probably due to natural section.

However, there is no evidence of absolute natural immunity of man to human malarial
parasites. There has been a degree of relative resistance to infection with P.Falciparum
in patients with Glucose-6-phosphate dehydrogenase deficiency and in children with
sickle cell trait (HBAS) or other hemoglobinopathies. Natural immunity can be reduced
by splenectomy.

Acquired Immunity
Immunity is due to stimulation of combined humoral and cellular (phagocytic) protective
mechanisms by previous infections. There is also transient acquired passive immunity
from the mother to child, mainly through the placenta and breast milk, but does not go
beyond six to nine months of age. The period between passive acquired and actively
acquired immunity to malaria accounts for the child's most dangerous malaria infections
in endemic areas.

Malaria antibodies in the blood neutralize the toxin of the parasite or interfere with its
multiplication. However, the immunity is strain specific. Acquired immunity of high
degree is associated with a high level of gamma-globulins in plasma, (IgG, IgM).

Vaccines
The mechanism for the protective role of antimalarial vaccine is poorly understood but
there is evidence that humoral (IgG and IgM), cell mediated responses (T-cells) and
non-specific responses (e.g., killer cells) are involved.

Efforts to produce useful vaccines to the malaria parasites are still in progress and there
are prospects that a broad-spectrum vaccine (which is effective against all antigens) will
be available before long.

SPF 66 - This is the malaria vaccine designed and produced by Prof. Manual Patarroyo
in Bogota, Colombia. SPF 66 is a synthetic peptide consisting of amino acid sequences
derived from three sexual stage proteins and derived from the circumsporozoite protein
of plasmodium falciparum.

This vaccine was initially received with skepticism after initial clinical testing showed
some success. Clinical tests done in Tanzania and the Gambia showed variable
results. The Tanzania study showed a clinical efficacy of 30-60%, while studies in the
Gambia, done in children under 1 year, showed no protection at all. However, this
study was one over a short period of time in a low malaria endemicity season.



162
REFERENCES

Jellife D.B. and Stanfield J.P. (eds) Malaria in: Diseases of Children in the Sub-tropics
and Tropics 3
rd
ed. The English Language Book Society and Edward Arnold
(Publishers) Limited 1982, 827 -856.

Morley, D. (ed): Malarial in Children. Paediatrics Priorities in Developing World. The
English Language Book Society ad Butterworths, London 1980: 248-256.

Malaria Control Programme, Ministry of Health, Uganda: Management of
Uncomplicated Malaria, A practical guide for Health Workers, 3
rd
ed, Kampala, 2005:
11-40.

Wilcokes, C. and Manson-Bahr P.E.C (eds): Manson's Tropical Diseases. The English
Language Book /Society and Bailliere Tindal, London, 17
th
Edition, 1976: 39 -86.

Parry E.H. O (ed): Communicable Diseases. Principles of Medicine in Africa. Oxford
University Press, Nairobi, Ibadan, 1976: 209-217.

Hendrickse R.G. Barr DGD, Mathews (eds) Malaria in: Paediatrics in the Tropics. 1
st
ed,
Blackwell scientific publications. 1991, 695-710.

Genton B, Smith T, Bae K, Narara A, et al, Malaria: how useful are clinical criteria for
improving the diagnosis in a highly endemic area, Trans Roy Soc Trop Med and Hyg.
(1994) 88, 537-541.

World Health Organization, Communicable disease cluster Department of prevention,
Eradication Social Mobilization and Training Unit: Diagnosis and Management of
Severe Falciparum Malaria, Uganda adaptation 2002.

Cox M.J. Kun D.E., Tavul L, Narfara A, et al: Dynamics of malaria parasitaemia
associated with febrile illness in children from a rural area of Mandary, Papua New
Guinea. Trans Roy Soc Trop Med and Hyg. (1994) 88, 191-197.

Brenan J.G. Campbell C.C. Combating Severe Malaria in African Children. Bull WHO
66 (5) 1988) 611-620.

Greenwood A.M, Armstrong R.M. Byass P, Snow R.W., Greenwood B.M: Malaria
Chemoprophylaxis, Birth Weight and Child Survival Trans Roy Soc trop Med & Hyg.
(1992) 86, 483-485.

Payne D. Use and Limitation of Light Microscopy for Diagnosing Malaria at the Primary
health Care Level. Bull. WHO 1988 66 (5) 621-626.

Malaria Diagnosis: Memorandum from WHO meeting. Bull. WHO (1988) 66 (5) 575-
594.
Hendrickse R.G, Adeniyi A: Quartan Malarial Nephrotic Syndrome in Children. Kidney-
Int 1979 July, 16 (1); 64-74.



163


CHAPTER 13

HIV INFECTION AND AIDS IN CHILDREN

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

INTRODUCTION
The term AIDS stands for Acquired Immune deficiency Syndrome. The first case was
reported in 1981 in the US among men who have sex with men. Uganda was the first
African country to report a case of AIDS in 1982. Between 1982 and 1986, AIDS cases
were identified in many other eastern and southern African countries. Since then
HIV/AIDS has rapidly evolved into a global pandemic. UNAIDS estimated that by the
end of 2006 there were about 40 million people living with HIV/AIDS globally. Within
Sub-Saharan Africa (SSA), southern Africa is the worst affected region. HIV infection
has increases child mortality and essentially wiped the gains made in promotion of the
child survival packages.

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

Describe the epidemiology of HIV/AIDS
Describe the modes of transmission of HIV/AIDS in children
Outline principles of HIV/AIDS prevention and control
The 4 pillars of prevention of mother-to-child transmission of HIV
The role of male circumcision in HIV prevention
Other modes of HIV prevention in children
Describe the natural history of HIV infections
Describe the diagnosis and staging of HIV in children
Laboratory diagnosis
Early infant diagnosis
Provider initiated testing
Clinical and immunological staging
Describe the management of HIV and its complications
The role of co-trimoxazole therapy
Isoniazid preventive therapy
Immunization
Nutrition
Treatment of OIs and other conditions
Antiretroviral therapy
Monitoring of ART
Psychosocial care and support

Learning activities
Visit an antenatal clinic and talk with staff on how mothers are counselled on being
tested for HIV



164
Does a role play to mimic testing and counselling in a clinic
During your obstetric rotation make sure you participate in the care of a mother with HIV
infection
Participate in the care of an HIV infected child
Explore how the community cares for an HIV infected family

THE EPIDEMIOLOGY OF HIV AND AIDS
The prevalence of paediatric AIDS is a direct reflection of the prevalence of HIV
infection in women of child bearing age. In sub-Saharan Africa, women represented
57% of all people living with HIV/AIDS. In eastern and southern Africa the prevalence
of HIV infection among pregnant women ranges from 6 to 40% in most countries
although in some regions in southern Africa prevalence rates exceed 50%.

The magnitude of the problem is shown in table 1. Without intervention, 30-40% of HIV
infected women will transmit the infection to their babies. The risk of transmission is
highest in women with high viral loads and in those with advanced disease. Mother-to-
child transmission of HIV can take place during pregnancy, at the time of delivery and
during breastfeeding. The estimated absolute transmission risk without intervention as
follows: 10% during pregnancy, 10-20% during delivery, and 10-20% during
breastfeeding. With the use of antiretroviral drugs HIV transmission can be reduced to
as low as 1% in non-breastfeeding populations and to as low as 5-6% in breastfeeding
populations.

Table 1: Estimated HIV Magnitude in Children aged <15 years in 2007

Number of Children <
15
Global Sub-Saharan Africa
Living with HIV 2.0 million 1.8 million
Newly infected with
HIV
370,000 330,000
Dying of HIV/AIDS 270,000 240,000

Without interventions HIV-1 infected children have a nine-fold increased risk of dying in
the first two years of life compared to non-infected children. If the mother dies,
regardless on the HIV infection status there is a 3-8 fold increased risk of death. The
ultimate goal for PMCT is to have HIV-free survival and therefore the strategies for
PMCT are geared towards preventing HIV transmission from mother-to-child and
promoting the survival of the mother and child.

There is evidence that sexually transmitted diseases (STDs) enhance the transmission
and acquisition of HIV. Recent evidence suggests that the key driver of the HIV
epidemic in Africa is the combination of the low prevalence of male circumcision and
high prevalence of multiple concurrent sex partner.








165
MODES OF TRANSMISSION
There are three main modes of transmission:

Mother to child transmission (MTCT) or vertical transmission
Contact with infected blood or blood products
Sexual contact or horizontal transmission

More than 90% of paediatric HIV infections are acquired through mother to child route.
Contact with blood or blood products may result in HIV infection through use of
unsterilized syringes and instruments, scarifications and transfusion with contaminated
blood or blood products. Sexual exposure especially in adolescents, sexual abuse (rape
and defilement both male and female), early marriage, prostitution and multiple
concurrent sex partners all increase the risk of sexual acquisition of HIV.

PRINCIPLES OF HIV/AIDS PREVENTION AND CONTROL
The 4 pillars of prevention of mother-to-child transmission of HIV
The role of male circumcision in HIV prevention
Other modes of HIV prevention in children
The “Four Pillars” of prevention of mother-to-child transmission of HIV
In populations affected by HIV the four pillars that are key promoting HIV-free survival of
children include:
Primary prevention of HIV in young people
Prevention (voluntary) of unwanted pregnancies in HIV infected women
Care and support of the HIV-infected woman
Promotion of the survival of the mother and other family members.

Primary prevention aims at prevention of HIV in young un-infected people. Strategies to
achieve this include the ABC strategy i.e. Abstain from sex, if not be faithful to your
partner and use a condom correctly all the time. Knowing one’s HIV status and that of
one’s partner; treating STDs and avoiding of intergenerational sex are important in
achieving primary prevention. Parents and caregivers can play an important role in
helping young people achieve primary prevention. Parental roles include: providing the
adolescence with a sense of being loved; respecting them as individuals; behaviour
control by setting limits; provision and protection; and modelling appropriate behaviour
for them. Current evidence shows that male circumcision can reduce the risk of
transmission by at least 60%. This is augmented by avoidance of multiple concurrent
sexual partners.

Voluntary prevention of unwanted pregnancies may be achieved through engaging in
less risk sexual behaviour; integrating counselling and testing in family planning
services; and through the use of effective family planning methods.

The third pillar involves the care and support of the HIV-infected woman during
pregnancy and lactation. The three most effective interventions with respect to
preventing transmission are HIV testing, provision of effective antiretroviral prophylaxis
and treatment and modification of infant feeding. HIV testing should be offered routinely
to all pregnant women in the antenatal clinics and maternity. Antiretroviral prophylaxis
should start early (28 weeks or earlier) and consist of at least AZT with single dose NVP



166
being used for those who present only in labour. At birth, all exposed infants should be
offered single dose NVP plus AZT for four weeks regardless of whether the mother
received prophylaxis. Mothers who meet treatment criteria should be commenced on
HAART as soon as possible. For further details refer to the latest WHO guidance on
antiretroviral drugs for treating pregnant women and preventing infection in infants.
Breastfed infant are at risk of HIV and this risk increases with the duration of
breastfeeding. Replacement feeding is the best way to prevent infection in such babies.
HAART in breastfeeding mothers significantly reduces the risk of transmission through
breastfeeding. When either HAART or replacement feeding are not possible, exclusive
breastfeeding offers the next best option for the survival of HIV exposed infants. Animal
proteins are required in complementary foods of non-breastfed babies in order to meet
their nutritional requirement.

The fourth pillar is to do with the survival of the family unit, that is, the mother, child and
other family members. For the woman this includes prevention and treatment of
opportunistic infections (co-trimoxazole and INH prophylaxis), psychosocial and
nutritional support, family planning and provisional ART if eligible. For the infant, the
essential package includes adequate nutrition, immunization, routine de-worming,
growth and development monitoring, treatment of acute infections, provision of
multivitamin and micronutrient supplementation, co-trimoxazole prophylaxis, early infant
diagnosis and provision of ART if eligible. For all other members of the family, HIV
testing and where appropriate OI prophylaxis and ART treatment should be instituted.

For successful HIV prevention in children, universal PMTCT coverage is essential.

For children surviving rape, defilement or needle-stick or sharps injuries, post-exposure
prophylaxis should be offered immediately without waiting completion of police
formalities. Male children should be offered safe circumcision before they reach puberty.

THE PATHOPHYSIOLOGY AND NATURAL HISTORY OF HIV INFECTIONS

HIV is retrovirus of the lentiviridae group. Several retroviruses have been described as
infections of various animal species (goats, sheep, cats and non-human primates).
These viruses characteristically are immunosuppressive or oncogenic. These viruses
are called retroviruses because they have the ability to make a DNA template from a
RNA strand. Three retroviruses have been documented to cause disease in man.
HTLV-1 causes T-cell leukaemia and Tropical spinal paralysis while HIV-1 and HIV-2
cause AIDS.

The virus is made of a RNA core surrounded by a glycoprotein (gp) envelope that has
several important components - gp 160, gp 120 and gp 41 - that facilitate the
attachment of the virus to the target cells. The virus has a predilection to immune
competent cells that contain the CD4++ receptor such as T4 cell tissue macrophages,
dendritic cells in the brain and Langerhan’s cells. Once the virus enters the cells it
makes the DNA template which them attaches and integrates into the cell genome.
Thus the cell is infected for life.



167
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.



168

THE DIAGNOSIS AND STAGING OF HIV IN CHILDREN

Laboratory testing
The mainstay of HIV diagnosis is the HIV ELISA antibody test. This assay is cheap and
relatively easy to perform. One can use a rapid test consisting of (a) Determine-
screening test (b) Stat Pak as a confirmatory test and (c) Unigold as a tie-breaker in
case of discordance. This is a reliable test and enables the patients to get their test
results within fifteen to twenty minutes. However, in young children (<18 months) whom
may have acquired HIV antibodies from their mothers, this method is not accurate. In
such children the more expensive but accurate DNA PCR is required to confirm the
diagnosis. This test removes the DNA (sometime RNA) from mononuclear cells and
amplifies sequences of genetic material which match the HIV virus and then tests for
the genetic material. It is currently the most accurate and sensitive method of
diagnosing HIV infection in young children. Although it is relatively expensive and
requires stringent laboratory conditions, costs have been declining and it is becoming
more widely accessible in developing country settings.

Early infant diagnosis
Definitive early infant diagnosis using Dry Blood Spot (DBS) can be achieved by
collecting blood on filter paper and sending it to a designated reference laboratory for
testing. In HIV exposed infants, DBS should be collected during the first postnatal visit
at 6 weeks or at first contact.

Provider initiated testing
All children presenting for sick child services should be offered HIV testing as part of
their care. Children of adults diagnosed with HIV or tuberculosis also should be
screened for HIV infection status.

CLINICAL AND IMMUNOLOGICAL STAGING
Clinical Staging
Clinical WHO HIV staging can help in diving infected children into those with no or mild
symptoms (WHO Stages I and II) and those with moderate or severe disease (WHO
Stages III and IV). This staging (see table 2) helps identify children who need immediate
antiretroviral therapy.

TABLE 2: WORLD HEALTH ORGANISATION CLINICAL STAGING OF HIV DISEASE
IN CHILDREN UNDER 12 YEARS WITH ESTABLISHED HIV INFECTION













169



CLINICAL STAGE I (ASYMPTOMATIC)
Asymptomatic
Persistent generalized lymphadenopathy
CLINICAL STAGE II (MILD)
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Fungal nail infections
Angular chelitis
Lineal gingival erythema
Extensive skin warts (papilloma virus or molluscum contagiosum)
Recurrent oral ulcers
Unexplained persistent parotid enlargement
Herpes zoster
Recurrent or chronic upper respiratory tract infections
(otitis media, otorrhoea, sinusitis, tonsilitis)

CLINICAL STAGE III (MODERATE)
Unexplained moderate malnutrition or wasting not adequately responding to standard
therapy
Unexplained persistent diarrhoea (14 days or more)
Unexplained persistent fever (above 37.60C, intermittent or constant, for longer than
1month)
Persistent oral candidiasis (after first 6-8 weeks of life)
Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis or periodontitis
Lymph node tuberculosis
Pulmonary tuberculosis
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained Anaemia (<8g/dl), neutropenia (<500/mm3) or thrombocytopenia
(<50,000/ mm3)
for more than 1 month

CLINICAL STAGE 4 (SEVERE)
Unexplained severe wasting, stunting or severe malnutrition not responding to
standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint
infection,
meningitis, but excluding pneumonia )
Chronic Herpes simplex infection (orolabial or cutaneous of more 1 month duration,
or visceral
at any site)
Extrapulmonary tuberculosis



170
Kaposi's sarcoma
Oesophageal candidiasis (or candida of trachea, bronchi or lungs)
Cytomegalovirus infection; retinitis or CMV infection affecting another organ, with
onset after
age 1 month
Central nervous system toxoplasmosis (including meningitis)
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
Chronic cryptosporidiosis (with diarrhoea)
Chronic isosoporiasis
Disseminated non-tuberculous mycobacteria infection
Cerebral or B cell non-Hodgkin lymphoma
HIV encephalopathy
Progressive multifocal leukoencephalopathy
HIV-associated cardiomyopathy or nephropathy


Presumptive HIV Diagnosis
In order to avoid delays in starting antiretroviral therapy due to lack of laboratory
confirmation, a presumptive diagnosis of HIV should be made if an exposed infant
presents with any stage III or IV conditions. Infants who are started on ART this should
have their diagnosis confirmed at the earliest opportunity.

Immunologic Staging
To identify children needing immediate ART the WHO has developed a system of
classifying the level of immune deficiency for HIV infected children using their absolute
CD4+ count or CD4+ percentage (Table 3).

CD4+% = (absolute CD4+ count per mm
3
/ total lymphocyte count per mm
3
) x 100.

Children with absolute CD4+ count or with CD4+% below that indicated in the table 3
are defined as having severe immuno-deficiency (severely immuno-suppressed).

Table 3: age-specific CD4+ Criteria for Severe HIV Immune Deficiency
Immunologic Category Age-specific CD4+ Criteria for Severe Immuno-
deficiency
< 18 months 18mo - 5 years 5 – 12 years
CD4+% < 25% < 20% < 15%
CD4+ count cells/mm
3
< 1500 < 750 < 350

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





171
MANAGEMENT OF HIV AND ITS COMPLICATION
Co-trimoxazole therapy
Prophylaxis against PCP especially in infants is associated with reduced mortality. All
infants should be started on prophylaxis until they are proven to be uninfected.
Generally this is started at six weeks to coincide with the first immunization.

Isoniazid preventive therapy
Preventing TB in children less than 5 years who are in household contact with an adult
with Tb is important. But before prophylaxis exclude active disease in the child.

Antiretroviral Therapy for HIV infected Children

The goal of Antiretroviral Therapy is to improve the quality of life and ensure normal
growth and development through the following:

Achieving complete viral suppression
Restoring the immune system
Preventing OIs

To achieve these goals it is necessary to use highly active antiretroviral therapy
(HAART), that is, a combination of a least three drugs which interrupt replication at two
or more sites in the viral replicative cycle.

RT
Provirus
Prot eins
RNA
RNA
DNA
DNA
RT
Viral prot ease
Reverse
t ranscript ase
Viral int egrase
RNA
RNA
Binding, f usion
and ent ry
DNA
ARV act ion sit es


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



172
resource restricted countries include reverse transcriptase inhibitors, non-nucleoside
reverse transcriptase inhibitors and protease inhibitors.

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

Table 4: Classes of Antiretroviral Drugs
Class of ARV Drug Name of Drug Use in children < 12
years
Nucleoside RTI
(NRTI)





Nucleotide RTI
(NtRTI)
Zidovudine (ZDV or
AZT)
Stavudine (d4T)
Lamivudine (3TC)
Didanosine (ddI)
Abacavir (ABC)
Emtricitabine (FTC)

Tenofovir (TDF)

Yes
Yes
Yes
Yes
Yes
No*

Selected

Non-Nucleoside RTI
(NNRTI)

Nevirapine (NVP)
Efavirenz (EFV)
Yes
Yes
Protease Inhibitor
(PI)
Nelfinavir (NFV)
Lopinavir/ritonavir
(LPV/r)
Indinavir (IDV)
Saquinavir (SQV)
Ritonavir (RTV)
Atazanavir (ATV)

Yes
Yes
Selected
Selected
Selected
No*
*May be used in adolescents.

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






173
Table 5: Criteria to Start ART in Children
Age Infants <
12 months
12 – 35
months
36 – 59
months
5 years and
over
CD4+ % All infants
require
ART
< 25% < 20% < 15%
Absolute CD4+
Count
< 750 < 500 < 350
WHO Clinical Stage 3 or 4 3 or 4 3 or 4

Preparing a Child for ART
Medical Preparation:
Do the following baseline tests to check bone marrow, liver and kidney function:
Full blood count (resources limited, do Hb)
Liver function tests (resources limited, do alanine transaminase or ALT)
Renal function tests (resources limited, do serum creatinine)
Do baseline CD4+ if possible and where indicated
Investigate for TB** if TB is confirmed, treat TB before initiating ARVs
Treat any inter-current illnesses
Nutritional counselling and supplementation where indicated

Counselling Preparation:
Counsel the parent/guardian on the following: Up to three adherence counselling
sessions may be necessary, however, if the caregiver has another child or she/he
herself/himself on ARVs this may not be necessary. Caregivers must be counselled on
when and how to administer the drugs, possible adverse effects of the drugs and how to
recognize them, and should be encouraged to bring the child on treatment back to clinic
if they have concerns or if the child becomes ill. Care should be taken not to overload
caregivers in one session as successful counselling is a continuing process and not an
event.

Table 6: First Line Antiretroviral Therapy
Child
Characteristics
Recommended Regimen
Child previously NOT exposed to nevirapine for prevention of mother-to-child HIV
transmission
Age below 3 years
or weight < 10kg
zidovudine (AZT)* + lamivudine (3TC) + nevirapine** (NVP)
or abacavir (ABC)
or stavudine (d4T)
Age above 3 years
and weight > 10kg
zidovudine (AZT)* + lamivudine (3TC) + nevirapine** (NVP)
or abacavir (ABC) or efavirenz (EFV)
or stavudine (d4T)
Child previously exposed to nevirapine (stat NVP for PMCT or breastfeeding while mother
on NVP-based ART)
All ages zidovudine (AZT)* + lamivudine (3TC) + lopinavir/ritonavir
or abacavir (ABC) (LPV/r)
or stavudine (d4T)
*In cases of severe anaemia (Hb < 7g/dl) or neutropenia substitute d4T for AZT





174

Immune Reconstitution Inflammatory Syndrome
Within weeks of starting HAART some patients may develop an acute inflammatory
syndrome that can be quite debilitating. These are severely immune depressed patients
in whom CD4+ cell recovery occurs rapidly. The ensuing inflammatory process as the
immune system responds to previously quiescent infection (e.g. TB or PCP) is called
immune reconstitution inflammatory syndrome (IRIS). Management of IRIS includes
identifying the underlying disease process and use of steroids may be required to
control symptoms. Patients developing IRIS or IRIS-like symptoms should be referred
for specialist care.

Follow up and monitoring
The frequency of visits, and clinical and laboratory monitoring that should be performed
during each visit is indicated below:

Table 7: Follow-up schedule monitoring schedule for patients on antiretroviral Therapy
Activity 1st Wk
2
Mth
1
Mth
2
Mth
3
Mth
6
Mth
9
Mth
12
Thereafter
in stable
patients
Weight, height
Clinical
evaluation
+ + + + + + + + Every 3
months
Check
adherence &
side-effects
+ + + + + + + + Every 3
months
Check ART
drug dosages
+ + + + + + Every 3 –
6 months
FBC
*
+ + + + + Every 6
months
LFT or ALT**

+ + + + + Every 6
months
Creatinine + + Every 12
months
CD4+ + (+) + Every 6-
12
months
Viral load
(HIV PCR)***
(+) (+) (+) Every 6-
12
months
Lipid profile,
fasting blood
sugar****
+ + + Every 6
months



175
*
FBC = full blood count; ** LFT = liver function tests. Minimum, assay serum alanine
transaminase (ALT or SGPT); *** RNA PCR for viral load; ****For children on protease
inhibitors; ( ) Parenthesis indicates test is optional, perform if affordable or if deemed
necessary.
At each visit:
Plot the physical growth of the child on growth chart.
Address ongoing medical problems; treat any intercurrent infections, if present.
Give co-trimoxazole prophylaxis and
Provide nutritional supplements (such as multivitamins)
Carry out and record an objective assessment of adherence.

The most important determinant of treatment success is adherence. Greater than 95%
adherence is necessary for optimal therapy that is one that ensures complete viral
suppression and maximal durability of the first line regimen. If a child misses more than
1 dose in ten days it implies < 95% (suboptimal) adherence, and health-worker should
counsel parent to identify causes of missed doses ways to address them immediately.

Psychosocial care and support
Children receiving ART and their caregivers do require psychosocial care and support.
Such support should aim to empower the child and the caregiver to cope with the
numerous challenges that they may face. These include stigma, feelings of depression,
helplessness, and loneliness. Studies indicate that chronically ill children who are
disclosed to in a timely manner have better outcomes compared to those who are not
disclosed to regarding the nature of their illness. A process of HIV disclosure that is
sequential and empowering and which involves caregivers in partnership with care
providers should be mastered by all those involved in the management of HIV infected
children. It is important to remember that HIV disclosure is not an event; rather it is a
process. Psychosocial support can be achieved through instituting the following
activities:

Peer clubs
Parents’ support groups
Organized outings e.g. Camp
Drama clubs
Classes for caregivers.





176
CHAPTER 14

ANAEMIA AND SICKLE CELL DISEASE

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

INTRODUCTION
Anaemia is defined as a reduction in haemoglobin level or oxygen carrying capacity or
blood below the level that is expected for age and sex. It is a world wide health problem
but especially in the developing countries. It is a common disorder in childhood where it
causes mobility and mortality. In an individual child with anaemia, there are usually
multiple causative factors.

At the end of this chapter, the student shall be able to:

Define anaemia
Describe the variation of haemoglobin level by age
Describe the morphological classification of anaemia.
Describe the various causes of anaemia
Describe the clinical tubes of anaemia
Describe the clinical features of anaemia
Describe the laboratory investigations for an anaemic child

8. Describe the management and prevention of anaemia

LEARNING EXPERIENCE
Practice the examining a child with anaemia in the clinic.
Participate in the planning for investigation of a child with anaemia.
Check on treatment chart how a child with anaemia is managed while on the ward at the
hospital.

Haematological Classification of anaemia

The basic causes of anaemia are grouped into four, namely:

Impaired haemoglobin production
There is a decreased rate of production of red cells. Here the bone marrow is aplastic
making it impossible to produce adequate red cells.
Deficiency in haematinics: Here too there is decreased production of red cells but due to
lack of raw materials. This occurs in iron deficiency. Folic acid and B12 deficiency
Blood loss (bleeding) which may be acute or chronic. In this category, the haemoglobin
is lost with the loss of red blood cells. This occurs in hook worm anaemia, in trauma,
and in hemophilia. It also occurs in leukaemias due to thrombocytopenia.
Haemolysis of red blood cells. This occurs in sickle cell anaemia and other
haemoglobinopathies. it also occurs in malaria






177
Red cell morphological types of anaemia

Besides measuring anaemia in terms of haemoglobin level, anaemia can be
categorized in three groups according to red cell size.

Microcytic Anaemia
In this group the red cells are smaller in size than normal. This occurs in iron deficiency
anaemia, thallasaemia and lead poisoning. The red cells in these diseases are pale,
being less filled with haemoglobin (hypochromic)

Normocytic Anaemia
In this group, the red cells are normal is size and are usually filled with haemoglobin
thus referred to as normochromic.
This occurs in Malaria anaemia acute blood loss anaemia. The cells in haemolytic
anaemias ( sickle cells anaemia) are in this category.

Macrocytic Anaemia
In this group, the average red cells are larger than normal. This occurs in folic acid
deficiency and in B12 deficiency.

Variation of Haemoglobin Level
Haemoglobin level varies with age. The level at which haemoglobin level indicates
anaemia also varies with age. At birth the haemoglobin level ranges from 16 to 18
gm/dl. In the neonate a haemoglobin level below 14.5 gm/dl is considered anaemia. At
8-12 weeks of life, the normal haemoglobin level is 11-12 gm/dl. In the age group 6
months to 12 months, the haemoglobin level is 12+gm/dl. At adolescent the
haemoglobin level rises to 14 – 15gm/dl. At that stage the cut-off level for anaemia is
9gm/dl.

Table – Haemoglobin level below which anaemia is present according to WHO

Age Hb gm/dl
6 months to 4 years 11
5 years to 11 years 11.5
12-14 years 12

Apart from this quantitative change in haemoglobin, there is a qualitative change in the
haemoglobin. At birth, the majority (50-95%) of haemoglobin is foetal haemoglobin with
only a small portion being adult haemoglobin. The foetal haemoglobin decreases rapidly
in inverse proportion to adult haemoglobin, so that by one year of age, only a small
amount of foetal haemoglobin is still present with majority being adult haemoglobin.


The specific causes of anaemia vary with the age of the child. In the newborn period for
example, anaemia occurs due to blood loss from umbilicus or bleeding from the
placenta during labour or as a part of ante-partum haemorrhage. In identical twins foeto-
foetal transfusion causes anaemia in one and plethora in the other twin. Anaemia also
results from haemolytic disease of the newborn, and haemorrhagic disease of the



178
newborn. In infancy on the other hand, anaemia is commonly caused by malaria, blood
loss and dietary iron deficiency. Aplastic bone marrow may also cause anaemia in this
period. Sickle cell anaemia which is prominent later can also cause anaemia in infancy.
In childhood, the major causes of anaemia are malaria, sickle cell anaemia and chronic
blood loss like hookworm anaemia, and dietary iron deficiency as in case of lack of
dietary iron or folic acid. Several other factors like infections, renal disease, leukaemias
can cause anaemia in this age group.

IRON DEFICIENCY ANAEMIA
Iron deficiency anaemia is of two types: nutritional and hookworm, the basic
mechanisms being lack of haemopoietic raw material and chronic blood loss
respectively.

Iron Metabolism: The foetus acquires its iron from the mother across the placenta.
This transplacental transfer of iron from the mother to the foetus is negligible during the
first and second trimester of pregnancy but it increases tremendously during the third
trimester. A foetus born prematurely does not have this benefit of acquiring the peak
transfer of iron. Foetal iron stores are 75mg/kg body weight both in the preterm and full
term infant but the preterm infant does not have large amount of total iron. A full term
infant born to a non-anaemic mother receives sufficient iron during foetal life to maintain
its needs for at least 3-4 months of infancy. The majority, seventy per cent, of the
neonatal iron stores is in the form of haemoglobin in the cells. The bulk of the remainder
is in storage form in the liver and other reticuloendothelial tissues. The other forms of
iron are myohaemoglobin, cytochromes, catalases and other iron containing enzymes.

Several factors occurring during pregnancy, childbirth and early neonatal period
contribute to the development of iron deficiency anaemia. In extreme maternal iron
deficiency anaemia, as occurs commonly in many tropical countries, the foetus acting
like a successful parasite has normal haemoglobin at birth, but runs short of iron stores
and develops iron deficiency anaemia in early infancy. Preterm infants out strip their
iron requirements when they grow rapidly since they have inadequate iron stores. Early
clumping of the umbilical cord denies the neonate blood which is in the placenta which if
allowed to be transfused into the baby, contributes so much haemoglobin. Early
clumping therefore predisposes to the development of iron deficiency. Blood loss from
the placenta in APH or from the cord at any time. or during foeto-foetal transfusion
causes iron deficiency. Generally, the following factors contribute to iron deficiency in
the preterm low birth weight infants:-

(i) Low iron stores at birth
(ii) Rapid growth and hence increased iron demands
(iii) Insufficient iron intake from the diet
(iv) Disturbance in iron balance from blood loss and infections, the latter of which is a
common problem in the preterm infants. In the preterm infants there is rapid growth and
unless there is adequate iron supplements, the relatively smaller neonatal iron stores
become rapidly depleted and anaemia develops by 2-3 months of age.

In infancy and childhood, iron absorption is regulated by several mechanisms namely:-



179
the amount of iron in the diet, the nature of the dietary iron, presence of phosphates and
phytic acid, presence of ascorbic and hydrochloric acid and the iron status of the body.
Cow’s milk has little iron but in human milk is also low in content but is of high bio-
availability and most of it is extracted and absorbed by the infant. Dietary iron is
absorbed in the upper jejunum. Inorganic (ferric iron), is changed to ferrous iron which is
then absorbed. Ferric iron is not absorbable. Hydrochloric acid and ascorbic acid
enhance iron absorption whereas phytic acids in cereals and phosphates inhibit iron
absorption. Iron containing haem compounds (Meat) is split from the protein complex to
globin and is absorbed directly. DMT-1 (divalent metal transporter) is involved in
transfer of iron from the lumen of the gut across the enterocyte microvilli. While
hepcidine, a regulator of intestinal iron absorption allows iron to enter portal plasma.
Low hepcidine levels in iron deficiency increases this process. After absorption through
gut mucosa, the iron is carried across the mucosal membrane and is carried by iron
binding protein to the liver and other reticuloendothelial tissues where it is stored or to
the bone marrow where it is utilized to form haemoglobin of red cells. There is a
mucosal block which controls absorption of iron. Approximately two-thirds of stored iron
is in the form of ferritin. The other stored iron is in the form of haemosiderin.

In childhood, the causes of iron deficiency, in addition to those mentioned in the infants,
are inadequate iron intake, hookworm infestation and malabsorption. Iron deficiency
occurs when there is absolute low dietary intake as when the infants and children are
not given iron rich food like cereals, green leafy vegetable or meats. Food may be
rendered deficient of iron through fault preparation as in overcooking of the green
vegetable. Infants who are on prolonged milk are not receiving a diet with good source
of iron. The other causation factor of iron deficiency anaemia is hookworm infestation
which is discussed elsewhere but suffice it to say that the severity of this type of
anaemia depends upon: worm load, age of the child, type of hookworm parasite and the
dietary iron intake. Ancylostoma duodenale sucks more blood than Nector americanus.
An adult Nector americanus sucks on average 0.15 -0.2ML of blood per day while
Ancylostoma duodenale sucks 0.05ML per day. The worm sucks the blood as it feeds. It
then wonders off to another site leaving the old site bleeding. Iron deficiency anaemia is
often complicated by other deficiencies such as PCM, pyridoxine, folic acid and nicotinic
acid. In such anaemia, response will not occur to administration of iron therapy alone
without correction of the other deficiencies at the same time.

Clinical Features: Iron deficiency anaemia occurs at any age and is most common in
infancy and pre-school children: 2-5 years of age. As the development of anaemia is
usually gradual, the children tolerate it well without development of symptoms. Such
patients are encountered on routine physical examination without symptoms
whatsoever. Children with severe iron deficiency anaemia, with haemoglobin levels of 3-
5gm% may walk into clinics without signs of decompensation and anaemia may be
discovered as an incidental finding, while the child is attending the clinic for some other
illness. Often, the children come to hospital for other illness like pneumonia which
precipitate cardiac decompensation.

The symptoms of iron deficiency anaemia are pallor, irritability, lethargy, lack of vigour,
easy tiring on physical activities, poor appetite, poor attention spurn, lack of alertness,
increased tendency to pyogenic infections and pica or eating soil.



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Clinical examination reveals a pale child, with pale skin, mucous membrane, sclera,
palms and soles of the feet and nail beds. There may be brittleness of the nails with
spooning of the nails, koilonychia. There may be history of melaena, dark stools
containing altered blood due to chronic bleeding from the gut. In severe anaemia, there
may be signs of cardiac decompensation, and heart failure such as tachycardia,
breathlessness, palpitation, cardiac enlargement, raised jugular venous pressure shown
by engorged neck veins and oedema of the feet or face. There is also gallop rhythm and
heart murmurs.

Laboratory Investigations: There are typical laboratory features of iron deficiency
anaemia. Usually the haemoglobin or haematocrit (packed cell volume, PCV) is low.
The peripheral blood smear is quite valuable and in itself alone the diagnosis can
confidently be made. The red cells are microcytic, small in size, hypochromic, lack
adequate colour, poikilocytosis, cell of various shapes, that is, distorted shapes. There
are increased target cells and elongated cells. Blood indices are low. Mean cell volume
MCV is reduced, less than 78, mean corpuscular haemoglobin (MCH) is low, less than
27 uug, and mean corpuscular haemoglobin concentration (MCHC) is less than 30
percent. Reticulocytes are either normal or reduced.

Confirmatory tests are rarely done. They include determination of serum iron, and total
iron binding capacity (TIBC) also known as transferring. Serum iron is low; normal
values are 120, but in iron deficiency levels of 10-60ug are found. Transferrin is
normally 450ug but this is usually a third, 150. Iron saturation is usually 32 percent but
in iron deficiency it is about10 percent. Bone marrow shows reduced or no
haemosiderin, serum ferritin is reduced to below l0ug/litre.

Laboratory investigations should also provide/ assistance in the causation of iron
deficiency anaemia. Stool is examined for hookworm ova and the worm load assessed.
Occult blood is also determined as a measure of blood loss in the gut. In tropical areas
where hookworm is a prominent factor in the causation of anaemia, the stool shows
variable quantities of hookworm ova, a feature of worm load.

Differential Diagnosis: There are a few conditions from which iron deficiency anaemia
should be distinguished. There are Thalassaemia minor and lead poisoning in which
microcytic hypochromic cells occur. A good history and physical findings would provide
assistance. In thalassaemia, there is a family history of the disease. The family has
relationship with Mediterranean people and the spleen and liver are enlarged. In chronic
lead poisoning, there is history of lead in the community particularly old lead paint.
Fortunately, lead paint is no longer manufactured.

Management: The management of iron deficiency anaemia begins with a correct
diagnosis and grading of severity of anaemia as well as establishing the underlining
causes. Where the cause is known as in hookworm iron deficiency anaemia, the
hookworms are eradicated by deworming as discussed elsewhere. In most cases, the
iron deficiency anaemia is mild or moderate and responds to oral therapy using ferrous
sulphate or ferrous gluconate. The recommended dose is 4.5-5mg/kg/day in three
divided doses given between meals. Iron can be administered with food or milk. Iron
therapy is given for a long time, usually 3-6 months to correct haemoglobin and



181
replenish iron stores in the tissues. The difficulty is ensuring that the medicine will be
taken while the child is at home. Administration of oral iron is followed by reticulocyte
response. The reticulocyte count which is initially low, increase in number and the
haemoglobin eventually rises. The patients with low haemoglobin have more rapid
response than those with higher levels. Lack of response by increase in reticulocyte
response or a rise in haemoglobin means a number of things:

(i) The oral Iron has not being taken at all, or
(ii Taken in inadequate amounts,
(iii) The diagnosis may be wrong
(iv) There is unrecognized blood loss
(v) There is impaired utilization of iron due to intercurrent infections or renal
disease.

Patients with malnutrition (PCM) will not respond to iron therapy alone without an
increased intake of protein. Administration of folic acid improves the response to iron
therapy as folic acid deficiency often coexists with iron deficiency. A quicker and a much
more effective way of correcting haemoglobin and replenishing iron stores is the
administration of parenteral iron such as iron dextran (Imferon) or iron sorbital. These
are indicated where there is severe anaemia or where the patient is not tolerating oral
iron. Parenteral iron can be calculated and given either as infusion or intramuscularly in
multiple sites. Where anaemia is very severe or life threatening, blood transfusion is
indicated to relieve hypoxia and save life. Care should be taken in giving blood
transfusion. As chronic hypoxia leads to weakened heart muscle, rapid blood
transfusion expands the plasma volume which the flabby cardiac muscles cannot cope
with, resulting in precipitated heart failure. To avoid such a calamity, several precautions
are taken namely:-

(i) Total blood given is calculated as 5m1/kg
(ii) Blood transfusion is given slowly.
(iii) Only red blood cells or packed cells are used.
(iv) Diuretics are given preceding the transfusion to avoid expansion of plasma
volume.
(v) Digitalization as prophylaxis to heart failure is done during transfusion, but this
is debatable as the drug is thought to be ineffective without heart failure.
(vi) Small packs of blood are preferred so as to avoid the danger of large
quantities of blood running in from a big 500m1bottle.
(vii) Evidence of heart failure is looked for in the course of blood transfusion and
transfusion stopped when signs start.

Prevention: Iron deficiency anaemia is prevented by various inexpensive methods.
During pregnancy, mothers should receive iron and folic acid tablets. This ensures good
iron stores in the foetus at birth. Iron supplement should be effected in all preterm
infants starting from the second week of life. During prolonged milk feeding iron
supplementation is advised. Iron rich foods such as a dark green leafy vegetables, meat
and cereals are recommended during infancy and early childhood. Normal infants
require 1mg of elemental iron daily which they obtain from dietary intake of 12-15mg of
iron.



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ANAEMIA DUE TO MALARIA
Anaemia of malaria is one of the three common causes of anaemia in tropical Africa.
The other two being iron deficiency and sickle cell anaemia. Red cells which are
parasitized by malaria parasites haemolyze easily as the parasites bust out on their
maturity. Cells which are parasitized are also trapped and destroyed in the
reticuloendothelial tissue, mainly in the spleen, bone marrow and liver. Plasmodium
falciparum attacks both young and old red cells while the other species of malaria
parasites, tend to parasitize the older red cells only. The resulting anaemia is therefore
much more severe in falciparum infection than in the other species of malaria parasites.
Peripheral blood smears show Parasitized red cells, polychromasia, anisocytosis,
poikilocytosis and target cells. The red cells are normochromic, normocytic.

Clinically, the patient has anaemia and the features of malaria namely fever, diarrhea
and vomiting, weakness, enlarged spleen anorexia and failure to thrive. The anorexia
may lead to dietary deficiency. Haemolysis depresses the bone marrow complicating
the picture of anaemia. Malaria parasitaemia may also depress bone marrow
temporarily. The treatment of anaemia of malaria focusses on both anaemia and,
malaria. Artemisin is given for malaria. When anaemia is severe, blood transfusion is
necessary and life saving. Blood transfusion is recommended at dosage of 10ml/kg.
Iron therapy is not useful unless there is concomitant iron deficiency anaemia.

SICKLE CELL ANAEMIA

Sickle cell anaemia results from a genetic disorder in the formation of haemoglobin.
Instead of the normal adult haemoglobin, these patients have abnormal haemoglobin in
their red cells. This abnormal haemoglobin crystallizes out whenever there is lowered
oxygen tension as occurs in pneumonia. The red cells with crystallized haemoglobin
become deformed in sickled cells which are picked up and haemolysed in
reticuloendothelial tissue giving rise to jaundice and anaemia.

The many the sickle red blood cells are destroyed by haemolysis, the severe is the
resulting anaemia. Much haemolysis occurs during attacks called crises. The more
frequent the crises occur, the more severe is the resulting anaemia, which is often
brought about by infections such as malaria and pneumonia. Exposure to cold during
cold season also precipitate a crisis.

Clinical Features
The child with sickle cell anaemia will have other clinical features of sickle cells disease
such as hand foot syndrome (swollen tender hand, finger feet and toes) these occur in
early infancy. The child will have abdominal pain and distension. The distension is due
to enlarged spleen and sometimes also enlarged liver. As they grow they also get pain
in the limbs and back.

The features for sickle cell anaemia will include; pallor of hand and soles of the feet and
nail beds, pale mucous membrane and pale conjunctiva. The sclera, and mucous
membranes, the soles of the feet and palms will be jaundiced. Patients with sickle cell
anaemia will in addition have cardiac enlargement with heart murmurs.




183
Laboratory Investigation
Haemoglobin level is low usually about 7gmldl. The red cells are normocytic and
normochromic. Sickling test is positive. Haemoglobin electrophoresis shows
haemoglobin SS instead of the normal hemoglobin AA.

Management
Throughout life the child with sickle cell anaemia should receive malaria prophylaxis to
avert malaria infection precipitating sickle cell crisis. The patient should be given daily
folic acid to replace folate last from the blood during sickle cell crises. Folic acid is
needed in the blood for the development of red blood cells otherwise megaloblastic
anaemia will develop as the body runs short of folic acid for normal synthesis of red
blood cells. Folic acid supplements is given orally in the dose of 2.5mg daily for children
below 5 years of age while those above 5 years of age receive 5mg daily. Iron should
not be administered to anaemic sickle cell patients. Normally the iron is stored in the
body following sickle cell crisis. Any additional iron is likely to cause iron poisoning.
Severe anaemia is management by blood transfusion.

Megaloblastic Anaemia
Megaloblastic anaemia is uncommon in tropical countries. When it occurs, it occurs on
infants early childhood in the form of folic acid deficiency and rarely due to B12
deficiency.

Folic Acid Deficiency
Folic acid deficiency is caused by (i) deficient intake (ii) deficient absorption of folic acid
dietary deficiency is usually corresponded by rapid growth in infancy and young children
or by infection which increase folic acid requirements. It also occurs in sickle cell
anemia as described earlier. The normal daily requirement is small, about 20-50 ug/day.
Human milk and cow’s milk have adequate amounts of folic acid. Powdered milk is a
poor source of folic acid and must be supplement. Ascorbic acid deficiency impairs the
availability of dietary folic acid conjugates. Routine folic supplements are recommended
for very low birth weight infants. Folic acid deficiency occurs in Kwashiorkor and
marasmus.

Vitamin B12 Deficiency
Dietary B12 is absorbed in combination with glycoprotein ( intrinsic factor) secreted by
the parietal cells of the gastric funds. The bi2 intrinsic factor complex that is formed
passes to the terminal item where specific absorptive sites exist. In the presence of
intrinsic factor and ionic calcium vitamin biz the intestinal mucous and enters the blood.

Vitamin B12 deficiency results from (i) inadequate intake (ii) lack of secretion of intrinsic
factor by the stomach (iii) lack of adequate consumption in inhibition of the B12 –
intrinsic factor complex of (v) abnormalities involving the receptor sites in the terminal
item. Vitamin B12 is present in many foods, dietary deficiency is rare. If may be seen in
extreme dietary restriction. Since vitamin bi2 is so common, the cases of vitamin biz are
normally due to failure to absorb the vitamin. Both folic acid and vitamin B12 deficiency
share some clinical features of anaemia with other deficiencies like iron deficiency.
Besides this, the affected infants with folic acid deficiency are irritable and have chronic
diarrhoea and stunted growth.



184
Laboratory features apart from the general low haemoglobin level include typical
megaloblasts and giant metamyelocytes and hypersegmented megakaryocytes.
Megaloblastic anaemia responds to folic acid administration in the daily dose of 5mg
daily for 2-3 weeks. Folic acid should be administered together with ascorbic acid. As
folic acid is the more common cause of megaloblastic anaemia, it should be given
alone. Dietary deficiencies of folic acid if considered should be corrected by giving
green vegetables proteins , liver and kidney which are rich in folic acid.

Aplastic Anaemia
Aplastic anaemia is a rare form of anaemia. It is caused by bone marrow failure. Where
bone marrow fail to produce. Red blood cells as well as white blood cells and the
platelets. This result in pancytopenia. It may be congenital or acquired. The acquired
form is sub divided into; idiopathic and secondary aplastic anaemia,. The idiopathic type
forms the majority of the cases being responsible for about 50% of the cases and has
no known aetiology. The congenital form of aplastic anaemia is also known as Fanconi's
anaemia and is associated multiple congenital defects involving the skeletal system,
skin, kidneys and the chromosomes. The skeletal defect includes: hypoplastic or absent
thumb and thenar eminence, absent radius, syndactyly and abnormalities of the long
bone. There are skin lesion such as hypopigmented spots and patches of pigmentation.
There may also be ptosis of the eyelids, abnormal ears and mental retardation.

The secondary form of aplastic anaemia results from a variety of insulting environmental
factors.

Table – agents that cause aplastic anaemia

Drugs: chloramphenicol, barbiturates, aminophylline, sulphonamides, nitrogen mustard
and 6- mercaptopurine

Toxic agents: infections, uraemia, herbs

Chemicals: DDT, lead

Physical agents: Radiation

Miscellaneous: haemolytic disorders such as sickle cell anaemia, hereditary
spherocytosis, multiple blood transfusions, and malnutrition

The incidence of aplastic anaemic vary according to the presence of the causative
factors.

The clinical features of aplastic anaemia depend on severity of bone marrow
involvement, the degree of anemia, and the coexisting causative agents. The patient
presents with failure to grow with stunting and wasting. There may be bleeding,
epistaxis, haematuria all due to thrombocytopenia. The level of anaemia is usually
profound with very low haemoglobin below 5 /dl. The patient is prone to infections.
Laboratory investigations show low haemoglobin level of normocytic normochromic
type. There are no normoblasts as in the case of leukaemia. Reticulocyte, white blood



185
cells and red blood cells are very low. Bone marrow trephine instead of bone marrow
aspiration is done and this helps in assessing cellularity of the bone marrow. From
these clinical and laboratory features together with history of exposure to toxic
substances drugs, infection and irradiation confirms the diagnosis.

Management of aplastic anaemia is fraught with difficulties. The main stay of treatment
is repeated blood transfusion. Unfortunately repeated blood transfusion may lead to
development of antibodies to blood making it difficult to continue with blood transfusion.

Repeated blood transfusion may lead to yet second problem that of haemosiderosis.
This can be anticipated and avoided by administration of desferrioxamine an iron
chelating agent administered during the course of blood transfusion. This chelates iron
from the tissues testosterone administration may stimulate red cell production leading to
a possible emission.
routine administration of antibiotics as a prophylaxis for infection can also be tried but is
safer to detect infection early and institute effective antibiotic treatment.


REFERENCE:

Akinkugbe F M Iron deficiency anaemia, East Africa Med J 55:151 1979

Bwibo N O Haemoglobin response following intramuscular imferon in children with
iron deficiency anaemia, East Africa Med J 47:254, 1976

Bwibo N O Haematological diseases in the tropics in: Paediatric Practice in
Developing countries, Editor GJ Ebrahim, McMillan Press Ltd, London 1981 pp 239-256

Eicholzer M, Tonz O and Zimmerman R Folic acid: a Public Health Challenge Lancet
367:1352, 2006

Ganz T. Hepcidin a regulator of intestinal iron absorption by macrophages clin
Haematol 18: 171, 2005

Shayeghi M, Latundo – Dada G O, Oakhil J S et al Identification of an intestinal heme-
transporter cell 122:789, 2005

Wang RH, Li C, Xux et all -A role of SONA D4 in iron metabolism through the positive
regulation of hepcidine expression Cell Met 2:399, 2005







186
CHAPTER 15

ADOLESCENT HEALTH, DRUG AND SUBSTANCE ABUSE

S. Bakeera-Kitaka, Amos Odiit, Samuel Ayaya, Esther D. Mwaikambo

INTRODUCTION
In many developing countries adolescents have not had special services made
available to them. Problems such as adolescent pregnancies, STIs, early marriages,
child labour, child prostitution, civil strife creating orphans, destitute children and the
generally unfavorable economic conditions, have all contributed to the deterioration in
the health status of adolescents; hence the need for separate adolescent health care
services. This has become even more critical because of the current HIV/AIDS
epidemic that is affecting mostly adolescents, especially girls.

The definition of an adolescent varies in terms of age limits, from one organization to
the other. The definition adopted in this book is that by the World health organization
which is: A person aged 10 – 19 years. The adolescent period can further be sub-
divided to:
Early adolescents (10 to 13 years,
Mid Adolescent (13 to 15 years)
Late adolescents (16 to 19 years).
Characterizing adolescents this way helps pick out the unique psychological issues that
are faced by different groups

The issue here is not so much the age definition of the adolescent but rather the fact
that SSS is characterized by a very young population with 50% of the population in
many countries being below 20 years of age. In 1990, 31% of Africa’s population was
between the ages of 10-24 years. This makes adolescents a large part of the general
population in any country in the SSA region. The health of the adolescent is therefore
very important in determining the future general and reproductive health of the
populations in the region. In SSA, the health problems of the adolescent population are
very similar. This chapter therefore discusses the major adolescent health needs, their
health problems, approaches towards, their management and the organization of
services that can adequately respond to their health needs, especially in SSA.

THE NORMAL ADOLESCENT
Reproductive biology development
Milestones in social responsibility
Risky behavior patterns and their consequences Recreation (sport, music, drama,
education) as viable alternatives that can maintain health and prevent major social
problems
What preventive and curative services are available for adolescents and where these
are?
Methods for the prevention of STDS and HIV infections
Methods for the prevention of drug abuse





187

Learning objectives
At the end of this chapter the student should be able to:

Define adolescent by age range according to WHO definition
Determine the size of the adolescent population in your country using available statistics
Describe methods used in determining the adolescent health status
List the priority adolescent health problems in your country and the African region.
Describe practical ways in which the community can be involved in development and
promotion of adolescent health.
Describe ways in which adolescent themselves can participate in improvement of their
health

Learning Activities
To facilitate learning, students will be exposed to and participate in activities targeted to
adolescents in the community in both rural and urban settings. These will include:

Assessment of adolescent health status to determine their knowledge, attitudes and
practices in a defined community
Identification of specific adolescent health problems in that community and in
determining possible solutions
Prepare a report describing the major adolescent health problems in that community
and the country and suggested ways to resolve them
Participate in peer education and a counseling activity lead by adolescent
Describe possible or ongoing activities aimed at improving adolescent health
Describe possible policy and programmatic actions that can lead to improved
adolescent health
Identify gaps in knowledge in the areas of adolescent health

Adolescent Sexual activity

Many factors such as early puberty breakdown of tradition norms and values, foreign
influence through television and media, economic hardships, urbanization and schooling
have led to more and more liberal attitudes and practices by adolescent leading them to
initiate sexual activity at an early age with about 80% of adolescents having their first
sexual intercourse by 19 years of age. Recent unpublished survey results from the rural
areas in East, Central and Southern, Africa have shown that 75% of girls interviewed
had their first sexual experience before the age of 16 years. Most of the sexual
intercourse was unprotected and could have led to infection with an STD or to
pregnancy.

Preventive actions should include:

Education on milestones in reproductive biology development and social responsibility
Promotion of appropriate behavior patterns to prevent early sexual indulgence.
Promote education to change risk behavior
Recreation (sports, music, drama, education)




188
Adolescent pregnancy and fertility

Teenage pregnancies contribute up to one third of all pregnancies in Africa South of the
Sahara. In East Africa they contribute to about 20-30% of all pregnancies occurring in
women aged 15 to 49 years while adolescents comprise 35% of all obstetric cases. It is
well known that teenage pregnancies have a higher incidence of complications and
maternal mortality. The DHS in the region have shown that adolescents contribute
about 11.5% of all births in Eastern and southern Africa suggesting that a large
proportion of adolescent pregnancies end up as abortions. Furthermore 81% of all girls
aged 15 to 19 years interviewed in Rural Kenya had at least one pregnancy. In addition
to the health risk that the adolescent pregnancy poses, such unplanned pregnancies
lead to high school drop-outs with loss of career opportunities and severe psychological
and social consequences.

Preventive Actions would include:
promotion of abstinence and
use of contraceptives.

Contraceptive use among adolescents

Few countries have liberalized contraceptive use for adolescents. Among these are
Botswana and Seychelles. Even in these countries adolescent contraceptive use is very
low. The reasons for this state of affairs is the negative perception that contraception
use is associated with multiple partners in the case of married couples and increased
sexual activity among the youth. In a four country study involving Tanzania, Seychelles,
Uganda and Zimbabwe undertaken by the Commonwealth Regional Community
Secretariat, results showed that whereas the contraceptive knowledge was as high as
80% among adolescents, use was as low as 5%. Similar results are available from the
DHS studies.

Promotion actions would include:
Education of adolescents on appropriate contraceptives and
Continued training of medical personnel and equip them with better counseling
techniques in relation to contraception for the adolescents.

Abortion among adolescents

In 1993 abortion contributed to 30% of maternal mortality in the countries of East
Central and Southern Africa. Over 20% of these were among teenagers. In Sub
Saharan Africa (SSA) 30-60% of all women hospitalized for complications of abortion
are teenagers. In a survey involving 1058 adolescent girls, 9% had attempted to have
an abortion. Of these, 53% had fallen ill and 25% had been hospitalized for treatment of
complications. Unsafe abortion is therefore a major problem among adolescents.

Preventive actions:

Education on the magnitude and consequences of unsafe abortion in terms of morbidity
and mortality



189

Promoting knowledge and attitudes that prevent the need for abortion through sexual
abstinence, contraception

Post-abortion counseling and contraception for adolescents to prevent repeated
unwanted pregnancy

Early Marriage

Many societies in SSA have cultural practices that encourage marriage of girls in early
adolescence. This is associated with fertility, reduced educational opportunities for the
affected, and health complications such as premature delivery, toxemia of pregnancy,
anemia obstructed labour, Vesico-vaginal fistulae (VVF) and various forms of injuries to
the birth canal. This is of particular importance in the rural areas where early marriage is
commonest and access to health care is least.

Preventive action

Public awareness of the negative effects of early marriage

Advocacy for protection of children’s and adolescent’s rights for education and career
development and in prevention of their sexual exploitation

Advocate for enforcement of law that prevent early marriages

Advocate for change of cultures and subcultures that practice early marriage

Sexually transmitted Infections, HIV/AIDS

Unprotected sex as is the practice among adolescents is associated with high incidence
of STIs. It is also true that adolescents are more biologically vulnerable to STIs due to
their immature physical development. In addition to these, economic forces that lead
adolescents to accept being used sexually for financial favors and often ending up in
prostitution all further exacerbate the likelihood of contracting an STI or HIV infection.
They are also misinformed about STIs and AIDS and thus unprepared to take
appropriate preventive action. An estimated 36% of women aged 15-24 had an STI. The
incidence of STIs and HIV infection are rising at a very high rate in the region. Public
awareness and practical preventive approaches must be developed and implemented.
These interventions must involve adolescents themselves. There is evidence that
aggressive treatment of STIs especially gonorrhea and genital ulcer disease is
associated with a 42% reduction in the incidence of HIV infection. This is an important
finding that must be made use of. Following increase of ARVs and PMTCT there is an
increasing number of children who acquired HIV infection perinatally and are now
reaching adolescence. This particular group of HIV infected children will sex education,
peer group support and readily available counseling services.






190
Management

Formal and informal education on the mechanisms of transmission of STDs and HIV
infection. School curricula must have adequate content in this regard. Similarly,
teachers must be educated on mechanisms of transmission of the common STDs, and
HIV and preventive activities, as they are an important source of information for the
adolescent.
Provision of special health service facilities that the adolescents are comfortable to use.
These should have diagnostic facilities, treatment and counseling.
Services for the diagnoses and treatment of STDs should be decentralized to the health
centre level to ensure easier access to the majority of the population.

Drug and Substance Abuse:

Adolescents like to experiment and take risks including using illicit drugs and alcohol.
The problem of drug and substance abuse in Africa has reached alarming proportions
although accurate data is not available. The drugs abused range from alcohol, tobacco,
various stimulants and the more addictive forms such as cannabis sativa, etc. Addiction
to drugs for the adolescent is often the end of the road in as far as education and career
development are concerned. Various factors have been blamed for drug and substance
abuse among adolescents. These include being idle, poverty, lack recreation during
leisure time, peer pressure, unemployment, lack of guidance and inadequate family
support.

Preventive actions

Put in place national policies that expressly prohibits drug trafficking and use,
accompanied by appropriate penalties and other preventive legal actions.
Undertake public education and create awareness on the dangers of drug abuse to the
society and the individual.
Develop treatment, counseling and support systems in the communities for individuals
diagnosed to be drug dependent.
Involve youth groups in programmes aims at the control of drug abuse.
Create community recreation centres
Encourage students in schools to join social and academic clubs and ensure presence
of such clubs in all schools in the country
Encourage and support peer education to improve adolescent health
It is recognized that peer education is a powerful tool to improve adolescent health.

It is important that adolescents themselves are involved in the identification health
problems and development solutions to the problems. Results of the commonwealth
study referred to earlier, showed that it was possible to involve the adolescents
themselves in the collection of the reproductive health data, and in the development of
interventions and in mobilizing community support of the programme. In addition the
study demonstrated a positive change in the knowledge, perceptions and practice on
sexuality especially among girls. After a year of intervention, there was demonstrable
positive change in knowledge perceptions and practice in sexuality, especially among
girls.



191


Special Problems of the Pre-adolescent Child:

The preadolescent girl is undergoing physical development, which may be interfered
with by malnutrition and lead to stunting of growth. This often leads to poor pelvic
development and cephalo-pelvic disproportion a common complication during child
birth. This can be prevented through community and school based health programmes.
A special predicament faces the preadolescent who is out of school. Even less services
are available to him or her whole being more vulnerable to neglect, communicable
disease, malnutrition and consequently poor physical and psychological development.

Current state of inadequate education in reproduction, sexuality and life skills essentially
allows them to enter adolescence without any preparation. This predisposes them
sexually transmitted diseases, and unwanted pregnancies. Pre-adolescent children
need at least minimum information regarding their own reproductive potentialities and
the problems associated with risky sexual behaviour.

In addition to health care provision to students, the education system should ensure
that curricula contain adequate health promotion and disease prevention topics. It is
accepted that the commonest source of most health information to school children in
this age group is the teacher. This is particularly true of reproductive biology and
sexuality. It is equally true that the primary school teacher has often not been prepared
enough to take up this task. There is urgent need to address this matter.

Health Care Services for the Adolescent
3 models are proposed:
Adolescent services integrated in Paediatrics
Purely adolescent service
Adolescent services integrated in adult care

In developing adolescent health services, emphasis should be made on making the
services Youth friendly. (A one “stop shop” with privacy). Services for the adolescent
should be integrated into the regular facilities of the clinics and hospitals but separate
from those of the adults and children. There is need to improve the available systems
through development of procedures, guidelines and protocols through:

For the Specially Disadvantaged Pre-adolescents and Adolescents:

Under this category falls the street children, orphans, mentally and physically disabled.
Over the last decade more than ever before there had developed a large population of
orphans due AIDS, civil strife, road traffic accidents etc; poor obstetric care leading to
birth asphyxia or other injury and adolescent pregnancy leading to abandoned children.
These are growing problems and not enough is being done for these groups. Special
programmes to identify them early and provide them with the necessary support


Community interventions to improve adolescent reproductive health:



192
Intervention matrix to improve some aspects of teenage Reproductive Health
Objective IEC content Activity Materials
To raise
awareness on
reproductive
potential
Concept of family
Puberty in boys
and girls
Emotional
changes towards
opposite sex
Discussions,
lectures,
demonstrations,
role plays,
simulations,
observations,
reading
Leaflets on puberty,
diagrams of
reproductive organs,
films on puberty
To educate on
endemic STDs in
the study area
Gonorrhea,
syphilis,
HIV/AIDS,
chancroid, pubic
lice,
Discussions,
lectures,
demonstrations,
role plays,
simulations,
observations,
reading
Leaflets on STDs
To enable youths
educate others on
HIV/AIDS
HIV/AIDS
transmission and
the disease
process
Discussions Films on AIDS
To educate on
dangers of
HIV/AIDS to youth
Dangers to the
individual the
family and the
nation
Group discussions
on dangers and
honesty about AIDS
Leaflets
To enable youths
avoid HIV and
other STDs
Sex in and out of
marriage, tips on
choosing a
spouse, saying no
as a contraceptive
Group discussions,
role plays, condom
use, demonstrations
Condoms
To enable youths
get counseling on
STDs
Where to get
services, and
description of
what happens
during counselling
Discussions, tour of
youth centres
The Youth Centre
To enable youths
describe
conception,
pregnancy and
childbirth
Ovulation,
ejaculation,
conception,
pregnancy, MCH
services, men and
MCH services
Discussions and
demonstrations
Leaflets, posters,
and reference books
To enable youths
learn tips of
responsible
parenthood
Responsible
parenthood, FP
services, FP
counseling
Discussions, tour of
youth centres
Physical address of
youth center,
leaflets, films
To enable youths
describe problems
of teenage
childbearing
Problems e.g.
injury,
complication,
responsibilities
Discussions,
distribution of
leaflets and posters
Posters, leaflets,
films



193

Priority Research Needs in adolescents

The field of adolescent health remains an elusive one. Little is known about factors that
determine the behaviour of adolescents and therefore what would be the best strategies
to adopt for various interventions. Operations research is therefore needed to
determine.

How to influence public opinion to improve the health of adolescents.
How best to organize adolescent health services in health care facilities and the
community.
How to integrate preventive and curative services in health care

















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CHAPTER 16

ACCIDENTS AND POISONING

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

INTRODUCTION
Accidents and poisoning are important causes of childhood morbidity and mortality
worldwide. Mortality is highest in the one to five year age group. Primary health care
workers need to be familiar with the common types of accidents and poisoning in their
own environment in order to be able to plan interventions and curative services as well
as setting strategies for prevention.

OBJECTIVES
At the end of this chapter, you should be able to:

List common types of accidents in your country
Indicate first aid measures and comprehensive management of each type.
List different circumstances in which accidents occur and describe measures for their
prevention.
List six common agents of poisoning in children.
Give the specific toxic effects, first aid measures and comprehensive management for
each type of poisoning.
List eight circumstances that predispose children to poisoning and describe measures
to prevent poisoning.
Describe the forms of poisoning and indicate the commonest cause of each in your
country and the relative importance as causes of morbidity and mortality.
Outline the management of a snake bite.

LEARNING ACTIVITIES
Spend time in the casualty department of your hospital and count the number of child
accident victims.
Participate in the management of an injured child.
Visit the burns unit in your hospital and observe the management of a child with burns.
Clerk a child with poisoning.
Visit the toxicology department in your area and discuss common types of poisoning
encountered
Visit a nearby zoo and learn about poisonous snakes.

Case illustration

Kamau aged four years and Otieno aged two years were well when their mother left
them asleep in the afternoon. The mother did not have a domestic helper so she locked
the children in the house. Two hours later when she came back she found her two
children unconscious on the floor. Clutched in the hands and scattered on the floor were
sugar coated aspirin tablets used by an older sibling with rheumatoid arthritis. The



195
mother rushed both children to the local General Hospital. One hour later, both children
were breathing fast, running a fever and convulsing.

Form a student group and discuss the following:

Question 1 What are the metabolic derangements that led to fever, fast breathing,
convulsions and coma in these children?

Question 2 What is the management of these children?

The doctor on call started treatment on both children. He carried out some
investigations and decided to refer the children to a tertiary care health facility.

Question 4 What investigations do you think these were?

Question 5 What therapy was the referring doctor hoping that these children would
receive?

Question 6 How would you prevent a similar occurrence in this family and your
community?

The secretaries during both discussions should be prepared to report back to the class
in a plenary.
The facilitator should move from group to group, observing the group dynamics and
generally be available for any questions and clarifications.

FACTORS THAT CONTRIBUTE TO THE OCCURRENCE OF ACCIDENTS AND
POISONING IN CHILDREN

1. Developmental stage
Accidents and poisoning are commonest in the toddler aged 9 months to the child aged
five years with a peak incidence in the age group of one to two years. At this age the
children are at a developmental age that is characterized by:

a strong exploratory instinct without a social conscience:
a strong desire for oral gratification- children of this age put things into the mouth as a
way of exploring them.
a different sense of taste from adults and they often like to swallow things that taste
strange or bitter to adults.
a strong desire to assert their own autonomy coupled with strong negative feelings that
drive a child to what is forbidden.



196
2. Gender
Although accidents and accidental poisoning are reported to occur more frequently in
boys, two Kenyan studies found an equal distribution in both boys and girls.

3. Child-caring practices
Lack of adequate supervision is probably the single most important contributor to
poisoning. In many rural and urban areas, young children are left in the care of young
siblings. Children aged 3 years or more are increasingly attending school and thus the
older children are not available to assist the mother with babysitting. A disturbing
pattern of child rearing is emerging where children less than three years of age are
sometimes left at home on their own, as mothers go to the garden or to the market. The
collapse of the extended family structure has led to limited options of alternative child
caring arrangements.

4. Poverty
Young children living in socio-economically deprived environments especially peri-urban
slums are at greater risk of accidents and accidental poisoning. This is because many
families now live in single room houses. As a result it is difficult to find a safe place to
store drugs and other poisonous agents, or even to be able to prevent exposure to
burns and scalds. The risk is further increased when both parents are either under
mental stress or are working away from home leaving the children under inadequate
supervision.

5. Children with special needs
The lack of special amenities for children with special needs results in parents having to
care for these children in their homes.

ACCIDENTS

Accidents can occur at any age as the child or adolescent interacts with his/her
environment. In developed countries, accidents are the leading causes of death in
children over the age of one year. In adolescents, alcohol and drug abuse contribute to
road traffic accidents.

Accidents can be classified as:
Household accidents which occur within and around the home.
They include falls from high surfaces, cuts and burns.
Out-door accidents that occur primarily away from home.
They include road traffic accidents, thorn pricks, animal kicks and bites, falls
from fruit trees and drowning.

The type of accident is determined by the child’s environment and gender. Among
school age children girls are most likely to experience burns and scalds in the house as
they assist their mothers with the house work while boys are more likely to be injured
outside as they tend animals or play.




197
The very young child is more prone to falling than the older child. The falls could be
from a bed, a high apartment building or a rough out-doors. Toddlers are more prone to
burns/scalding compared to older children.

Two studies were carried to document the prevalence of accidents in Marigat Division a
rural area in Kenya and in Kibera urban slum of Nairobi. The peak occurrence of
accidents was in the under fives and the prevalence was comparable in boys and girls.

Table I: characteristics of accidents in urban and rural populations below 20 years of
age in Kenya.

Characteristic Urban population Rural population
(Kibera urban slum) (Marigat-Baringo district)
N=1576

Prevalence of accidents 111(7%)
Age distribution
0-4 67.8% 51 (56%)
5-9 34 (30.6%)
10-14 17 (17.1%)
15-19 7 (6.3%)
Types of injuries
Puncture wounds (stings, bites, thorn pricks) 55 (49.6%)
Burns/scalds 29 (26%)
Incisive wounds 11 (9.9%)
Fracture dislocations 5 (4.5%)
Others 11 (9.9%)
Falls 50.5%





ROAD TRAFFIC ACCIDENTS
Road traffic accidents are a major global public health problem and worldwide, the
number of people killed in road traffic accidents each year us estimated at 1.2 million.
Deaths from road traffic injuries account for around 25% of all deaths from injury.
Among both children aged 5-14 years and young people aged 15-29 years, road
traffic injuries are the second-leading cause of death worldwide. In Nairobi it is
estimated to be the leading causes of death in children aged 5-15 years. Children are
involved in accidents as passengers, cyclists or pedestrians crossing roads to school or
while playing near or on the road.

Management of Road Traffic Accidents
The management of road traffic accidents depends on the severity of the injuries. A
quick history and examination should be carried out to establish the severity of the
injuries.




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The following steps should then be taken: -

1. Establish a clear airway and support respiration if necessary.
2. Control any bleeding- a simple pressure bandage may very useful, but
bleeding arteries may require to be sutured to arrest bleeding.
3. Make a quick appraisal of the blood loss and treat shock if present. Look for
internal haemorrhage remembering the possibility of ruptured viscera and
massive bleeding into tissues.
4. Clean and debride wounds before stitching.
5. Immobilize fractures immediately and plan to set them when the patient is
stabilized.
6. Carry out necessary investigations such as x-ray while continuing to closely
monitor the patient.
7. Administer tetanus toxoid
8. Give analgesics to relieve pain.

Prevention of Road Traffic Accidents

1. Adequate supervision of children.
2. Children should be taught the basics of road safety at school or at Children’s
Traffic clubs.
3. Adequate play ground space and recreation in order to prevent children from
playing near or on the road.
4. Public education to increase knowledge and utilization of road safety
measures pertaining to children such as infant car seats, safety belts, bicycle
crash helmets and wearing reflectors when walking in the dark.
5. A road traffic system designed for safe sustainable use.

BLUNT-TRAUMA, CUTS AND FALLS

Blunt trauma, cuts, falls, and puncture wounds are common accidents in children. Cuts
usually results from objects such as knives in the household or farming implements as
children work in the garden. Blunt injuries follow episodes of assault or animal kicks.

Falls are an important form of injury and were found in the studies described above to
be common in the urban environment while puncture wounds were common in rural
areas. Small babies fall from high surfaces where they have been left unattended. In a
few occasions head injuries followed by mental retardation and epilepsy have occurred.
In urban areas toddlers and even school aged children fall down the stairs and from
apartment buildings with inadequate safety measures while school aged children may
fall from trees or from jumping off moving vehicles. Falls from a height put children at
risk of hip injuries.

Thorns pricks are important in rural areas where children walk bare footed. The wound
may become septic and may be a source of tetanus. The principles of management are
as detailed above.





199

DROWNING AND NEAR DROWNING MANAGEMENT

Children run the risk of drowning when they play around water without adequate
supervision. High risk groups include toddlers, preschool children and patients with
seizures. A toddler may drown in a bucket or basin filled with water. Older children in
rural areas drown in rivers, pit latrines and excavation sites filled with water.

Management

On the scene Resuscitation

1. Initiate ventilation -clear the mouth of any debris and hold the child upside down and
pat on the back to facilitate the removal of inhaled water and then do mouth to mouth
resuscitation.
2. Start external cardiac massage if there is no palpable pulse.
3. Give oxygen at the earliest opportunity.

In Hospital

1. All children with near drowning should be admitted for at least twenty four hours
observation, no matter how well they look.
2. Cardiopulmonary resuscitation should be continued until spontaneous breathing is
restored.
3. Children who fail to respond to the above measures should be transferred to an
intensive care unit.

Burns

Burns cause 10% mortality of all hospital admissions. It is estimated that 20 people per
million population die from burns with half of them dying before hospital admission.
Children account for a large proportion of all burns admission in eastern and southern
African countries. Burns are a leading pediatric surgical emergency. They are
responsible for 30% of acute paediatric surgical admissions and, like other accidents
and poisoning, the peak incidence is between one and three years of age.

Scalds are most important burns in childhood usually from hot tea, water and porridge.
The majority of burns occur at home. In the Margate study 82% of the burns were in
children aged less than five years and there were significantly more girls who were
burnt than boys. The possibility of child abuse should always be considered when a
child presents with burns.

Burns Wounds Management
First aid
The burnt body part should be immersed immediately in cold water to cool the tissues
and to prevent further progression of the burn. The burnt area should be covered in a
clean cloth and health care should be sought from the nearest facility.




200
Hospital Management of Burns
There are two methods of treating burns, the open method and the closed method. In
both methods one aims to provide an aseptic environment so that the burn can heal
rapidly. In second and third degree burns topical antibiotics are indicated. The drug of
choice is sulphadiazine although, silver nitrate, povidone-iodine, and gentamicin
ointments have been used.

Open method

In the open method, the burn is left open and a topical agent is applied twice daily. This
method has an advantage in that bacterial growth is not enhanced. However, it has the
disadvantage that the wound is more painful and there is increased fluid loss.

Closed method

An occlusive dressing is applied after a topical agent is applied.
There is an increase in the re epithelialization of the wounds but the method has the
potential of increasing bacterial growth.

In major burns the following should be done:
1. Determine the percentage of body surface area burnt.
2. Determine the degree of the burn whether superficial, second degree or third degree.
3. Treat pain with analgesics.
4. Determine the fluid loss which occurs through oozing.
5. Monitor the urine output.
6. Treat any infection.
7. Give tetanus toxoid.

Prevention of Burns
1. Make sure hot liquids, fire and match boxes are not accessible to children.
2. Young children should be adequately supervised.
3. The fire places should be out of reach of young children.

POISONING
A poison is any substance that causes harm if it gets into the body. Harm can be mild
(for example, headache or nausea) or severe (for example, fits or very high fever), and
severely poisoned people may die. Almost any chemical can be a poison if there is
enough in the body.
Acute exposure is a single contact that lasts for seconds, minutes or hours, or several
exposures over about a day or less. Chronic exposure is contact that lasts for many
days, months or years.
Routes of Exposure
Through the mouth by swallowing (ingestion)
Most poisoning happens this way. When poisons are swallowed they go to the stomach
from where they are absorbed into the blood. The longer a poison stays in the gut the
more will be absorbed into the blood and the worse the poisoning will be.
Through the lungs by breathing into the mouth or nose (inhalation)



201
Poisons in the form of gas, vapour, dust, fumes, and smoke or fine spray droplets may
be breathed into the mouth and nose and go down the air passages into the lungs.

Through the skin by contact with liquids, sprays or mists
Children may be poisoned if the chemical is sprayed or splashed onto the skin, or if they
wear clothes soaked with chemical.
By injection through the skin
Poisons can be injected through the skin from a syringe, or a pressure gun, or during
tattooing, or by the bite or sting of a poisonous animal, insect, fish or snake. The
injection may go directly into the blood stream or under the skin into muscle or fatty
tissues.
Epidemiology
Poisoning is divided into accidental poisoning and non accidental or self poisoning.
Most cases of accidental poisoning occur within the home. The poisoning agents are
usually household agents, medicaments and plant material. General characteristics of
poisoning include:

1. Poisoning accidents in the home happen to young children aged between 1 and 4
years with a peak at 2 to 3 years. At this age children want to explore. They can crawl
or walk round the house on their own and by the age of 2 they can probably climb onto
a chair to reach a high shelf. They can open drawers and cupboards, and they may be
able to open screw-top bottles. After the age of five years and particularly in developing
countries poisoning often occurs in groups, usually of friends, for example following food
poisoning, pesticide and carbon monoxide poisoning.
2. Accessibility of the poisoning agent is the single most important environmental risk
factor. Paraffin is the commonest poisoning agent in this region. Children of health
workers who have large amount of drugs in the house or siblings of children on chronic
treatment with drugs such as anticonvulsants, or major tranquillizers are at increased
risk of poisoning
3. Most drug containers in use in the region are easy to open and do not have a child
lock

4. Many pediatric drug preparation are sugar coated or sweetened and may be
mistaken for sweets.

5. Seasonal variations in poisoning occur. In farming areas it is noted that hospital
admission due to chronic heavy metal poisoning occur more in the rainy months
probably from increased use of agro-chemicals for farming purposes. Carbon monoxide
poisoning is common during the cold season whereby a lighted charcoal burner in a
room without adequate ventilation is the usual cause.

6. Illiteracy contributes to the risk of poisoning in that individuals who are unable to read
will be unable to follow safety precautions written on the labels of various drugs and
chemicals.

7. Inadequate labeling of drugs and chemicals increase the risk of poisoning. It also
leads to lack of recognition of poisoning and late institution of appropriate therapy.
Unfortunately health workers often fail to label the drugs that they dispense.



202
8. Administration of the wrong drug or the wrong dose; for example caregivers may
administer different brand names of the same medicine or they may give larger doses
than those prescribed with the hope of speeding up recovery. There are instances
where health workers have administered the wrong medicine or the wrong dose with a
fatal outcome.


Non-Accidental Poisoning (Self-poisoning)
Self poisoning is usually seen in older children and adolescents suffering from
depression, serious illness, or alcohol dependence in an attempt to commit suicide or to
attract attention.
Non-accidental poisoning is commoner in girls than boys, but the males are more likely
to be successful with their suicide attempt compared to females. The agents that are
commonly used in suicidal attempts are organophosphates.

Consequences of Poisoning

The effects of poisoning maybe none, mild or severe depending on:
The amount of poison ingested.
The nature of the substance
The age of the child.
The nutritional status of the child.
The state of the stomach-whether empty or full of food.
The effects of poison
The effects of poisons can be local or systemic. A local effect is limited to the part of the
body in contact with the chemical A systemic effect is a more general effect that occurs
when a poison is absorbed into the body.
Local effects
On the skin chemicals can cause itching, rash, pain, swelling, blisters or serious burns.
In the eye irritant or corrosive chemicals can cause severe pain, burns, scars or even
blindness. Irritant or corrosive chemicals may lead to damage in the mouth, throat or
inside the stomach. The child will present with abdominal pain, vomiting, diarrhoea,
haematemesis and melaena stools. If the throat is burnt it may swell very quickly, so
that the child cannot breathe.
Inside the air passages and lungs irritation from vapours and gases can cause
coughing, choking and lung oedema
Systemic effects
There are many ways in which poisons can cause harm by damaging organs such as
the brain, nerves, heart, liver, lungs, kidneys, or skin. Poisons can also lead to muscle
paralysis.
When there is acute exposure, the effects happen soon after exposure and do not last
very long. But, in some cases, the effects of a poison are not seen for several hours or
even days after an acute exposure.
Common Substances Causing Poisoning in Children
The commonest substances causing poisoning in East and Southern Africa are
household chemicals followed by drugs.





203
Table II: Substances causing poisoning in children


Poisoning agents Example

Household Agents Paraffin,
Organophosphate pesticides (malathion, diazinon)
Carbamate (rat poison), disinfectant, bleach
Medicaments Aspirin, paracetamol,
Anti-convulsant drugs (carbamazepine, phenobarbitone),
Haematinics (iron and vitamins)
Major tranquilizers (phenothiazines)
Some herbal therapies

Plants Mushrooms, datura stramonium (the young leaves being
confused with amaranthus leaves)

Food and beverages Alcohol,
Herbal teas (crotalaria, heliotropium)
Aflatoxins on inadequately stored grains
Cyanide in incompletely cooked cassava leaves,
Contaminated food stuff (Botulism, salmonellosis)



MANAGEMENT
The management of the poisoned child is at two levels; at home where first aid is
administered and in the hospital where specific treatment is given.

First aid at home

First aid treatment should be administered by the person who finds the child after the
poisoning episode. Care should be taken so that the first aid treatment does not cause
severe complications that may be worse than the original poisoning.

The aim of the first aid is to remove the poison before it is absorbed or to delay or stop
the continued absorption of the poison.

1. The mother or the care provider should give a lot of fluids, for example milk or
milk mixed with raw egg to induce vomiting. Administering milk mixed with raw
egg provides proteins that readily bind the poison. Saline solutions should be
avoided because they lead to electrolyte imbalance.
2. Children who are poisoned by paraffin or a corrosive agent should not be made
to vomit.







204
3. Containers of medicines or poisons should be brought along to the hospital for
identification.

Treatment in hospital

The clinician should take a brief history, examine the child thoroughly and rapidly and
then do the following:

1. Ensure a clear airway and support respiration.
2. Treat shock if present.
3. Remove poison from the body before it is absorbed, by inducing vomiting or
doing a gastric lavage except when kerosene or a corrosive has been
ingested.
4. Reduce absorption by administering activated charcoal which absorbs many
toxins and prevents subsequent absorption.
6. Anti-dotes should be used but these are available for very poisons.
7. General supportive measures are important to ensure adequate hydration,
temperature control, fluid and electrolyte balance, nutrition intake and control
of convulsions and cardiac arrhythmia.

Table III: Antidotes to some poisoning agents.

Poisoning agent Antidote
Heavy metals Dimecaprol (BAL), EDTA
Iron Desferrioxamine
Narcotics Naloxone
Nitrites and nitrates Methylene blue
Phenothiazines Diphenyhydramine (Benadryl)
Organophosphates Atropine



PARAFFIN (KEROSENE) POISONING
Paraffin poisoning is the commonest type of poisoning in children in east and southern
Africa. Paraffin is a common household agent used as a fuel for cooking and lighting. It
is commonly stored in beverage bottles and children ingest it thinking it is a beverage.
Paraffin poisoning should be suspected from the history or the smell of paraffin on the
child’s breath.

Small amount of paraffin cause minimal symptoms. A 10 ml dose may be fatal. A dose
of 1 ml/kg causes central nervous system (CNS) depression which manifests as
drowsiness and coma. A history of coughing, choking, wheezing and fast breathing as
well as vomiting is suggestive of aspiration resulting in a hydrocarbon pneumonia that
takes several weeks to resolve completely. Weakness, dizziness, headaches and coma
also occur. An acute hemorrhagic necrotizing disease has been described, evolving
over 24 hours and resolving spontaneously over 3-5 days.
Management of paraffin poisoning




205
1. Induction of emesis is contra-indicated because it facilitates the aspiration of
paraffin into the lungs.
2. In severe poisoning a cuffed endo-tracheal tube is used to aspirate the poison
from the stomach.
3. All children presenting with a history of paraffin poisoning should be observed
in hospital for 6 to 24 hours.
4. Supportive care, including oxygen and mechanical ventilation, should be given
as needed. For repeated fits diazepam should be given by intravenous injection.

ORGANOPHOSPHATE POISONING

Organophosphates are commonly used pesticides. Poisoning can occur as a result of
inhalation, skin contact or through ingestion. Organophosphates are ingested
accidentally by children or deliberately by adolescents. Children working in the agro-
industry maybe exposed to inhalation during the spraying of crops such as coffee. The
symptoms of organophosphate ingestion occur within 30-60 minutes.

Mild poisoning presents with anorexia, and tremors of the tongue and eye lids, while the
older child may complain of impaired vision, headache, dizziness, weakness, anxiety,
and substantial discomfort.

Moderate poisoning is characterized by nausea, salivation, tearing, abdominal cramps,
vomiting, slow pulse and muscular fasciculation.

Severe poisoning presents with severe diarrhoea, difficulty in breathing, pinpoint and
non reactive pupils, pulmonary oedema, coma, hyperglycemia, and rarely acute
pancreatitis.

Treatment of organophosphate poisoning

Treatment depends on the severity of the poisoning; in a severely poisoned child the
priority should be to establish an airway, administer oxygen, reduce respiratory
secretions through suction, and control convulsions if present.

Specific treatment:

1. Administer atropine until atropinization is achieved - pupils become fully dilated
and the mucus membranes become dry. The dose of atropine is repeated 30 minutes
until full atropinization. Interruption of atropine has been associated with development of
fatal pulmonary edema or respiration failure. The patient should be observed for 3-4
days to ensure that the poison has cleared from the body.

2. Immediately remove contaminated clothes, shoes, socks and jewellery.
Decontaminate the skin, nails, hair and mucus membranes by washing with
soap and copious amounts of cold or lukewarm water for at least 15 minutes.
Be careful not to get any of the chemical on your own skin or clothes, or
to breathe in vapours. `Gastric lavage or vomiting should be induced if no
symptoms have appeared.



206
3. Give activated charcoal to absorb any organophosphate that may be in the
gut.

4. Administer the specific antidote-PAM 1 mg in aqueous solution through a slow
intravenous infusion. This drug should be given after achieving full
atropinization. The drug can be repeated in 30 minutes but can only be given
twice in a 24 hour period. This drug is only useful in the first 24-48 hours after
an episode of poisoning. It can be given intramuscularly if an intravenous dose
cannot be given. Obidoxime chloride can be used if pralidoxime is not available.

ASPIRIN (SALICYLATE) POISONING

Accidental aspirin poisoning is common in young children. The poisoning is suspected if
the child has a history of ingesting aspirin containing tablets or multiple drug therapy by
the mother with different generic forms of aspirin. Acute on chronic salicylate poisoning
may occur in children on chronic treatment with salicylates.

Aspirin uncouples oxidative phosphorylation which results in excess heat production,
excess sweating leading to dehydration. Aspirin interferes with glucose metabolism
resulting in hyper-or hypoglycaemia.

The patients often present with hyperventilation, sweating, dehydration, and sometimes
diarrhoea and vomiting. In moderate poisoning the respiratory centre is stimulated
resulting in respiratory alkalosis to which the kidney responds by producing alkali and in
the process K+ is depleted and H+ is substituted resulting in acidic urine.

Aspirin poisoning causes metabolic acidosis in the young child that is classified as mild
(blood pH>7.4 and urine pH>6.0), moderate (blood pH<7.4 and urine pH<6.0,) and
severe (blood pH<7.4 and urine pH is <6.0)

In severe cases convulsions and coma occur. Older children may present with vomiting,
hyperpnoea, lethargy, tinnitus, and sudden deafness.

Management of salicylate poisoning

1. Emesis followed by a gastric lavage using a wide bore gastric tube should be
carried out. Salicylates have been recovered in the gut up to 20 hours after
ingestion.

2. To prevent further absorption of ingested salicylates, activated charcoal should
be administered every 4 hours until charcoal appears in the stool.

3. Serum electrolytes, especially Potassium and Bicarbonate, as well as serum
and urine pH should be monitored. Urine pH is easily monitored in the side-
lab using urine dipsticks.

5. Mild aspirin poisoning can be managed successfully with oral fluids. Oral
rehydration solution (ORS) is ideal in that it provides at least 30meq/I of



207
Bicarbonate and 20meq/l of K+. Urine pH and that serum salicylate should be
monitored.

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

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

8. If the patient is able to take fluids orally ORS, orange juice, bananas and milk
are useful in alkalinizing urine. 1.5g of KCL may be added to 1 liter of ORS to
increase the K+ content to 40 meq/liter.

9. Vitamin K should be administered to prevent possible haemorrhage.

10. Haemodialysis is indicated in patients presenting with renal failure or
pulmonary oedema.

11. For repeated fits, diazepam should be given by intravenous injection.

IRON POISONING
Iron poisoning in children is related to the availability of iron containing tablets in the
house. Severe iron poisoning will depend on the amount of elemental iron that is
absorbed.
Five stages of intoxication occur:
haemorrhagic gastroenteritis 30-60 minutes after ingestion of the iron and maybe
associated with shock, acidosis and coma. This phase lasts 4-6 hours.

Phase of improvement when patient looks better and lasts 2-12 hours.

Phase of delayed shock that occurs 12-48 hours after ingestion and is usually
associated with a serum iron level of>500mg/dl. Metabolic acidosis, leukocytosis and
coma may occur; there may be hyperglycaemia at first and hypoglycaemia later.

Liver damage with hepatic failure.

Residual pyloric stenosis that usually develops 4 weeks after the initial poisoning. A
plain abdominal x-ray will demonstrate the un-absorbed tables in the stomach.
Diarrhoea, vomiting, leucocytosis (>15, 000µL), hyperglycemia, and a positive
abdominal x-ray have been shown to correlate positively with a serum iron of>300µg/dl.



208

Management of iron poisoning
1. Emesis and gastric lavage using a large bore nasogastric tube should be
carried out.
2. Do not give activated charcoal because it does not bind iron.
3. Desferrioxamine should be given to all patients with signs and symptoms of
severe poisoning such as shock, unconsciousness, convulsions, severe
vomiting or acidosis, or a serum iron concentration greater than 5 mg/l. It can
be given intramuscularly or intravenously.

PREVENTION OF POISONING

1. Safe storage of drugs and household agents, out of reach of children and
preferably under lock and key.

2. Safe packaging of drugs and chemicals in unattractive colours in child safe
containers.

3. Containers of food and beverages should not be used to store drugs or
harmful chemical agents.

4. Health workers should give health education on safe use of drugs dispensed
to patients.

5. Unused medication should be disposed of.

6. Chemicals and drugs should be clearly labeled with the pharmacological or
chemical names. There should be clear indications of their use, safety
precautions relating to handling and storage as well as some information on
their toxicity and anti-dotes, whenever available. Drugs which are dispensed
in hospitals should be clearly labelled, with the strength of the preparation and
frequency of administration indicated.

7. Public education on safe handling of agro-chemicals. This should include the
use of protective clothing, storage of agro-chemicals and disposal of empty
containers by burying.

8. Manufacturers should be encouraged to pack agro-chemicals in small
packages to meet the needs of the peasant farmers. The containers should
be clearly labeled indicating contents, safety precautions and disposal, in the
commonly used language.

9. Non accidental poisoning is a psychiatric emergency that can be prevented by
developing good communication and a supportive environment for the
adolescents within the family.






209
SNAKE BITES
Snake bites are common in rural, peri-urban and hilly areas. Children and adolescents
engaged in outdoor play are the most vulnerable group. Most snakes are non-
poisonous. However the mambas, viperidae (true vipers) and afro-asian cobras are
some of the deadliest snakes. It is important that the health workers be familiar with the
common snakes in the area and their physical appearance in order to determine
whether the attacking snake is poisonous or not.
All snake bites should be considered potentially dangerous and urgent treatment should
be instituted.
Snake bites are more serious in the children because of the relatively large volume of
venom injected into the small volume of a child.
The snake bite victim is usually frightened and unable to give history. Examination of
the wound is useful since bites by non poisonous snakes lack distinct fang marks and
there is no swelling or pain.

Clinical features of a poisonous snake bite

- Bite site: pain, swelling, tissue discoloration and regional lymph node swelling.
- Hemorrhagic symptoms: bleeding at the wound site, venipuncture sites,
epistaxis
and bleeding in other body parts is pathognomonic of a snake bite.
- Danger signs: drowsiness, slurred speech, excessive oral secretions, difficulty
in breathing and coma.

Management of snake bites
First aid
When a patient has been bitten on the extremities a tourniquet should be applied
proximally. The tourniquet should be tight enough to occlude venous and lymphatic
return BUT PRESERVE THE PULSE. The involved limb should be immobilized and
kept in a slightly elevated position. Cold packs should not be applied on the limb and
maybe harmful. The patient should be kept quiet and transferred to a hospital
immediately. If transportation is not immediately available an incision (1 cm length and
0.5 cm depth) should be made between the fang marks after cleaning the area. The
flow of blood helps to wash the toxin away.
Hospital management
1. Excise a block of skin and subcutaneous tissue 1 cm around the fang marks if
a dangerous snake was involved and the bite was within 2 hours.
2. An intravenous line should be established to enable administration of
emergency drugs as the need arises.
3. Tetanus toxoid should be administered to all patients with a snake bite.
4. A full blood count should be carried out.
5. Blood should be grouped and cross matched in readiness for a transfusion.
6. Paracetamol may be given for pain
7. If the wound becomes infected, treat with antibiotics
8. Rapid spread of swelling and progress of symptoms is indicative of the need
to administer anti-venom. Anti-venom should be administered as per the
manufacturer’s instructions. On average children need 50% more anti-venom
than adults.



210

REFERENCES

1. World report on road traffic injury prevention. World Health Organization. 2004

2. Ogden KW.Safer roads. A guide to road safety engineering. Melbourne,
Ashgate Publishing Ltd, 1996.

3. Reece R.M. and Godin M.A. Injury and injury prevention. Pediatric Clinics of North
America, 1985, 42-60

4. Bwibo N. Poisoning and accidents in Diseases of children in the tropics and
subtropics. Eds Stanfield P, Brueton M, Chan M, Waterston T.ELBS Edward Anorld,
Hodder and Stoughton, Kent, UK.

5. Baures P. The management of the road traffic victim. Post graduate doctor. June
1984. vol. 6 page 174.

6. Hendrickse R.G; Aflatoxins and Kwashiorkor in children in Africa. Post graduate
doctor 1985. vol. 7, No.11, page 348.

7. Dreisbach RH. Handbook of poisoning, eleventh edition. Lange medical publications
1983, Los Altos, California.

8. Management of Poisoning: A handbook for health care workers.
World Health Organization, Geneva, 1997

9. Watt CH. Poisonous snake bites treatment in the United States. JAMA 1978;140
(7):654-6

10. Oloo MA. Prevalence study on accidents in persons under twenty years of age in
Marigat Division, Baringo. MMed (Paed) Dissertation, University of Nairobi.

11. Yuko AC and Kitili PN. A prevalence study of accidents and poisoning in persons
under 20 years of age in a Nairobi slum, Kibera, Laini Saba. Unpublished manuscript,
Department of Paediatrics, University of Nairobi.

12. Rumack BH. Poisoning in Current Paediatric diagnosis and treatment.8
th
edition.Ed.
Kempe CH, Silver HK, O’Brien D. Lange Medical Publications, Los Altos, California.












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CHAPTER 17
CARDIOVASCULAR DISEASES IN CHILDHOOD
Christine Yuko-Jowi, Gabriel Anabwani

The commonest childhood cardiovascular problems are congenital and rheumatic heart
diseases. These two causes account for the majority of patients being seen with heart
disease in most east and southern African countries. Congenital heart diseases are
malformations of the heart and blood vessels which are present from birth. Rheumatic
heart disease results from an inflammatory process of the heart following upper
respiratory infection by beta haemolytic streptococcus. Less common causes of heart
disease in children include viral myocarditis and pericarditis, connective tissue diseases,
Kawasaki’s disease, tuberculous pericarditis and heart disease due to nutritional
deficiencies.

CONGENITAL HEART DISEASES
Eight of every thousand children who are born alive have congenital heart
malformations which account for up to 33% of all deaths during the entire neonatal
period. The majority of these defects are likely caused by chance errors during the
development of the cardiovascular system. However, some congenital lesions have
been linked to genetic, environment factors. Majority of patients with critical congenital
heart disease will present during the first year of life. About a third of children with
congenital heart disease has mild heart abnormalities and never requires any treatment.
Therefore it is important to identify congenital heart disease early and to refer affected
children for specialist care.

How Can One Identify Functionally Important Heart Diseases In Infants And Children?

Suspect congenital heart disease in any newborn, infant or child who presents with any
of the following symptoms:

Cyanosis (blue discoloration of lips, tongue or hands)
Fast breathing (tachypnoea)
Laboured breathing
Feeding difficulties
Failure to gain weight
Sweating
Pallor
Irritability and
Lethargy

Older children may complain of shortness of breath with exercise, fatigue, dizziness or
palpitations. Chest pain and syncope may be associated with lesions that obstruct the
flow of blood. History may reveal evidence of poor maternal health such as diabetes or
chronic alcohol or drug use.







212

How does one examine a child with a suspected heart problem?

The traditional examination format of inspection, palpation, percussion and auscultation
should be followed. Initial rapid assessment should include the following three steps;

Step 1: Assess whether the infant or child is acutely ill or potentially stressed and
therefore in urgent need for referral for further investigation and management
Step 2: Check if the infant cyanotic or Acyanotic.

Step 3: Assess if the patient is outwardly well, has minimal symptoms or is
asymptomatic

What should one look for during inspection?
A lot of information can be gained from initial inspection before the child is disturbed.
A sick infant with a heart problem often appears anxious, may have pallor, sweating,
tachypnoea and dyspnoea. The infant might be hungry for air, dislikes being handled
and even tolerates handling poorly. During inspection the respiratory rate should be
counted.
Is there skin pallor to suggest low output?
Is the infant cyanotic or acyanotic?
Is there evidence of finger clubbing?
Is there periorbital oedema or jaundice?
Is the precordium abnormally shaped?
Are there any dysmorphic features?

What should one look for during palpation?
Pulses are assessed for rate, rhythm, volume and character. The criteria for
tachycardia is a heart rate of more than 150 beats per minute in a resting infant and
more than 120 beat per minute in the child.
Jugular venous pressure: This examination is reliable in an older child where it is
indicative of high right side pressures.
The apex beat: The position and character of the apex beat should be noted since it
helps to assesses ventricular hypertrophy and/or dilatation. In young infants or child the
apex beat is normally at the 4
th
intercostals space along the midclavicular line. When
the left ventricle is dilated the apex beat is displaced downward and inferiorly and is
hyperactive. An apex beat which is on the right side may indicate dextrocardia or
malposition of the heart.
Parasternal heave: Is felt along the left sternal edge. A hypertrophied right ventricle
produces a parasternal tap. When it lifts the hand is suggestive of right ventricular
dilatation.
Thrill: Is a palpable murmur and is indicative of a loud murmur. The precordium,
suprasternal and carotid areas should be palpated for thrills.
Hepatomegaly: Is the hallmark of systemic congestion in an infant. The normal liver in
an infant may be palpable 2 to 3 cm below the right costal margin. When enlarged the
liver is palpable more than 3 cm below the right costal margin, and may be tender.




213
PERCUSSION: Percussion of the chest is an important part of a respiratory
examination but is of limited value in a cardiac examination.

What should one look for during auscultation?
Auscultation of the normal heart has to be learned over a period of time in order to
appreciate abnormal auscultatory findings. It is necessary to achieve a quiet
environment during cardiac auscultation. Any abnormal findings on auscultation should
be referred.

Heart sounds: A loud first heart sound is associated with mitral stenosis. A fixed split
second heart sound is associated with atrial septal defects. The second heart sound
may be loud in severe pulmonary hypertension whereas it may be soft or inaudible in
pulmonary valve stenosis.

Murmurs: Are usually the main reason why paediatric patients are referred to hospital
for cardiovascular assessment. Murmurs may be systolic, diastolic or continuous.

Types of Congenital heart disease
For simplicity these lesions are generally divided into acyanotic and cyanotic congenital
heart disease. The acyanotic lesions may be due to communications between the left
and right side of the heart leading to increased blood flow to the lungs and include
ventricular septal defects, patent ductus arteriosus and atrial septal defects. Lesions
which obstruct the flow of blood pulmonary valve stenosis aortic valve stenosis and
coarctation of aorta.
Common cyanotic congenital heart diseases include the “5T s” Tetralogy of Fallot,
Transposition of the great vessels, Tricuspid atresia, truncus arteriosus and Total
anomalous pulmonary venous return.

Investigating congenital heart disease
Chest X-ray- useful in demonstrating cardiac shape and size, and in assessing the
pulmonary vasculature. The pulmonary vasculature is increased in left to right shunt,
decreased in right to left shunts.
Twelve lead electrocardiogram- this can demonstrate heart rate and rhythm, and
chamber enlargement.
Two dimensional echocardiogram and colour flow maps- this is currently the main tool
in diagnosing congenital heart diseases- in terms of the type of malformation and the
heart function
Diagnostic cardiac catheterizations – this is useful in assessing the anatomy in complex
congenital heart diseases and in some situations special catheters are used to treat
some diseases.

Common Examples of Congenital Heart Disease

Ventricular Septal Defect (VSD)
A VSD is a defect in which opening exists between the two ventricles. This is the most
common form of congenital heart disease comprising of 30%. A VSD can exist as an
isolated lesion (simple VSD) or in association with other lesions as part of a more
complex cardiac malformation. Small isolated defects may be asymptomatic. Larger



214
lesions present with frequent chest infections, failure to grow and tachycardia. In the
absence of pulmonary hypertension the second heart sound is normal on auscultation.
A long or pansystollic murmur is heard best along the lower left sternal border. A chest
radiograph shows cardiomegaly with increased pulmonary vascular markings. An
electrocardiogram shows left ventricular hypertrophy when the VSD is large. Two
dimensional Echocardiogram is the best tool used to diagnose the type and size of
VSD, and any associated complications. Cardiac catheterization may be useful in
assessment of pulmonary pressures in selected patients. Small or moderate VSDs may
close spontaneously. However, large VSDs can cause irreversible complications or
heart failure and are treated by surgical closure. Figure 1 is a two dimensional picture of
a VSD.

Figure 1: A VSD as shown on two dimensional echocardiography.
















Pulmonary Valve Stenosis (PS)
Pulmonary stenosis or narrowing is the second commonest type of congenital heart
disease comprising of 20-40% of congenital heart defect cases and causes obstruction
of blood flow from the right ventricle to the pulmonary arteries and lungs. It is commonly
associated with maternal rubella, maternal warfarin therapy and Noonan’s syndrome.
Pulmonary valve stenosis presents with a soft second heart sound and an ejection
systolic murmur along the left upper sternal border. The mild cases are usually
asymptomatic while severe stenosis presents with right heart failure. A chest radiograph
may show right ventricular hypertrophy with normal pulmonary vascular markings. An
electrocardiogram shows right ventricular hypertrophy PS is severe. Two dimensional
echocardiogram with colour flow Doppler is the best tool used to confirm the diagnosis
of PS and any associated complications. The treatment of choice is through therapeutic
cardiac catheterization involving balloon dilatation of the valve.








LV
RV
VSD
LA
AV



215




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



Atrial Septal Defects (ASD)
This is defect in which an opening exists between the left and right atriums (the upper
two chambers of the heart). Because pressures are higher in the left atrium, blood
returning from the lungs is shunted from the left atrium to left right atrium from where it
goes back to the lungs. The defect can occur in isolation (simple ASD) or in association
with other congenital heart defects. ASDs are commonly asymptomatic, the only clinical
sign being a fixed split second heart sound on auscultation. A systollic murmur is best
heard best along the upper left sternal border. A chest radiograph shows right
ventricular cardiomegaly with increased pulmonary vascular markings. An
electrocardiogram shows right ventricular hypertrophy when the ASD is large. Two
dimensional Echocardiogram is the best tool used to diagnose the type and size of
ASD, and any associated complications. Cardiac catheterization may be useful in
assessment of pulmonary pressures in selected patients. Chest pains, palpitations,
arrhythmias and heart failure present late presentation, often in adult life. When
diagnosed early, surgical repair or balloon occlusion should be performed electively
before school age at 4-5 years.

Patent Ductus Arteriosus (PDA)
The patent ductus arteriosus is a communication between the aorta and the pulmonary
artery at the level of the aortic arch. It remains open in the intrauterine period and is
useful way by which blood bypasses the non-functional lungs to reach the aorta. In
normal full term infants it closes immediately or soon after birth. In preterm infants, it is
commonly open but may but may close if it is small. If it fails to close then its
persistence leads to heart disease. The clinical presentation includes bounding or full



216
pulses and continuous murmurs along the left upper sternal border. A chest radiograph
may show cardiomegaly with increased pulmonary vascular markings. An
electrocardiogram shows left ventricular hypertrophy when the PDA is large. Two
dimensional echocardiogram with colour flow Doppler is the best tool used to confirm
the diagnosis of PDA and any associated complications. Cardiac catheterization may be
useful in assessment of pulmonary pressures in selected patients. Treatment is by
surgical ligation or occlusion using special devices as soon as the diagnosis is made.
Untreated PDA can lead to congestive cardiac failure, pulmonary hypertension and is
prone to infective endocarditis.

Figure 3- Catheterization diagram of a patent ductus arteriosus.


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



217
be dilated using balloons and stents during cardiac catheterization.

Cyanotic Congenital Heart Disease

These congenital malformations are complex and associated with morbidity and
mortality during the neonatal period. They present with central and peripheral cyanosis.

Tetralogy of Fallot
This is the commonest type of cyanotic congenital heart disease, presenting with
cyanosis and a systolic murmur within the first month of life. This abnormality has four
basic components: a large ventricular septal defect, pulmonary subvalvar and valve
stenosis, overriding aorta and right ventricular hypertrophy. The patients can sometimes
present with extreme cyanosis and hyper cyanotic or “tet” spells. Hyper cyanotic spells
can be life threatening and often need urgent recognition and management.
Management of the spell includes putting the child in knee chest position, giving
intravenous fluids to improve on the hyper viscosity, propranolol to improve the
infundibular spasms and peripheral resistance. Morphine and sodium bicarbonate may
be indicated in severe states. Treatment of tetralogy of Fallot is surgical , either
palliative by putting a Blalock-Tausig (BT) shunt, or total correction through open heart
surgery to resect the pulmonary infundibular and close the VSD using a patch.

RHEUMATIC HEART DISEASE
Epidemiology
The first attack of acute rheumatic fever is likely to occur between the young school
ages of 5-15yrs. Crowding from inadequate housing, crowded classrooms and
dormitories is probably the main risk factor in acquiring streptococcal pharyngeal
infection and resulting in acute rheumatic fever. There is no difference in sex, race or
ethnic susceptibility to acute rheumatic fever. Rheumatic fever does not follow group A
streptococcal infections from other sites such as pyoderma. Proper treatment of acute
Aortogram showing
coactation of the aorta



218
pharyngitis virtually eliminates the risk of acute rheumatic fever; lack of access to good
medical care remains a risk factor to developing ARF. Although the prevalence of acute
rheumatic fever appears to be declining even in developing countries, the profile of the
disease appears to be changing, now running a sub acute course and the severity of
the cardiac process has not ameliorated.

Aetiology and Pathology
Rheumatic heart disease follows an untreated throat infection by group A beta-
haemolytic streptococcus usually after a latency of two to three weeks. It is believed that
the infection precipitates an acute rheumatic fever, an autoimmune diffuse inflammatory
disease of connective tissue involving chiefly the heart, joints, brain, blood vessels and
subcutaneous tissues. The major importance of acute rheumatic fever comes from its
involvement of the heart. As the valves heal from the rheumatic process, there is
thickening, fibrosis and shortening of the leaflets leading to regurgitation (leaking) and
Stenosis (narrowing of the valves). The most affected valves in the heart are the mitral
and aortic. The tricuspid and pulmonary valves are rarely involved.

Clinical Presentation and Diagnosis
Physical findings of acute rheumatic fever can be non-specific and misleading.
Therefore, a high index of suspicion is required for diagnosis. The most commonly used
criteria for diagnosis of rheumatic fever are the modified Jones criteria shown below.
Two major criteria or one major plus two minor criteria plus evidence of recent
streptococcal infection are required for definitive diagnosis.

Major Criteria Minor criteria
Carditis Previous rheumatic fever
Arthritis Arthralgia
Chorea Fever
Erythema marginatum Acute phase reactants
Subcutaneous nodules First degree atrioventricular block

c) Evidence of previous streptococcal infections:
Raised ASOT titers
Positive throat cultures
Recent scarlet fever




219
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.













220
Figure 1-Two dimensional echocardiogram Parasternal long axis showing
thickened and clubbed mitral valve leaflets and dilated left ventricle.

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

Table: 1 Antibiotics used in secondary prophylaxis of Rheumatic Fever

Antibiotic Mode of
Administration
Dose
Benzanthine
penicillin
Single I/M
monthly
1.2 mega units if
wt>30kg
Single I/M
monthly
600,000 units if wt
< 30kg
Penicillin V Oral 250mg BD
Sulphonamide Oral 1gm daily if
wt>30kg
500 mg daily if
wt<30kg
Erthromycin Oral 250 mg twice daily

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

Table: 2 WHO recommendation for secondary prophylaxis of Rheumatic Fever

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

10 yrs after last attack
More severe valve disease Life Long
After valve surgery Life long



221
Other therapeutic measures
Rest: Patients with carditis should have bed rest until the signs of cardiac inflammation
have subsided.

Antinflamatory agents: Acetyl salicylic acid (Asprin) has dramatic effect on arthritis but
has no effect on carditis. High doses are used (70-100 mg/kg). Corticosteroids are used
in patients with carditis. Prednisone 1-2mg kg/day divided in one or two doses for two
weeks and tapered over a week.

For Sydenham’s chorea Haloperidol 0.5- 1mg /kg (maximum dose 5mg) until symptoms
are controlled. Prolonged treatment may be required in some patients especially those
with recurrent symptoms.

Heart failure may occur in severe carditis or rheumatic valvular disease. Patients with
heart failure should managed with oxygen, rest, fluid restriction, furosemide (1-2 mg/kg
per day) and digoxin 0.125 mg od. Patients with heart failure as well as those with
carditis or cardiac complications should be referred for specialist care.

Chronic Rheumatic Heart Disease
Chronic rheumatic heart disease results from fibrosis or scarring of the myocardium and
heart valves. Fusion of the valve apparatus result in stenosis or a combination of
stenosis and insufficiency. Fusion occurs at the level of the valve commissures, cusps,
chordal attachments, or any combination of these. Rheumatic heart disease is
responsible for 99% of mitral valve stenosis. Recurrent episodes of RF lead to
progressive damage to the valves. Associated atrial fibrillation or left atrial thrombus
formation from chronic mitral valve involvement and atrial enlargement may be
observed. Severely damaged valves may need valve replacement or repair.




















222


CHAPTER 18

COMMON SKIN DISEASES IN CHILDREN

Samuel Ayaya, Amos Odiit, Esther D. Mwaikambo

INTRODUCTION
The skin is the largest organ in the body. It protects us from the environmental hazards
such as ultraviolet light and infections among other functions. Skin problems are
common. Many of these problems never present at health care facilities as the parents
may think they are minor and indeed some of the heal without treatment. Usually by the
time a child is brought to a health facility there are either multiple lesions or have the
lesions have not responded to home care remedies. Skin lesions may be part of a
systemic disease or an allergic reaction. HIV/AIDS which presents with skin diseases in
over 90% of the cases has increased the prevalence of skin conditions.

The purpose of this chapter, therefore, is to enable the student understand basic
dermatological terminology, recognize common skin diseases in children and
adolescents and treat them.

Objectives:
At the end of this chapter, the student should be able to:
Define and identify primary and secondary skin lesions.
List the common skin diseases seen in children.
Recognise common skin diseases.
Understand common dermatological investigations.
Treat the common skin diseases.
Use topical steroids rationally.

Learning Experiences:

Visit the dermatology clinic in your Medical School.
Watch Kodachrome slides of skin diseases. Or use a dermatological atlas preferably
based on the dark skin.
Clerk patients with skin diseases.
Attend some practical sessions in the Department of Microbiology to perform some of
the tests.
Attend sessions in the Department of pathology to observe the histology of the skin
diseases.

Primary and Secondary Skin Lesions

To identify a skin lesion one has to consider the following about the lesion:

Whether there is colour change.
The lesion is raised or flat.



223
Contains fluid or not.
Type of fluid is in the lesion.
Widest diameter of the lesion ( < 1cm ).

Definition of Primary Skin Lesions

These are the lesions that occur when the skin disease starts, without interference by a
physical activity. They include:

Macule - Flat lesion that measures 1cm or less in diameter.

Patch - Flat lesion that measures more than 1cm in diameter.

Papule - Elevated lesion that is 1cm or less in diameter and does not
contain fluid.

Nodule - Elevated lesion that measures more than 1cm in diameter
and depth.

Plaque - Elevated lesion that measures more than 1cm in diameter, is
flat topped without substantial depth.

Vesicle - Elevated lesion that measures 1 cm or less and is filled with
clear fluid.

Bullus - Elevated lesion that measures more than 1cm and is
(Blister) filled with clear fluid.

Pustule - Elevated lesion that is filled with cloudy or purulent fluid

Cyst - Nodule that is filled with expressible material that is either liquid
or semi-solid.

Petichiae – pinpoint bleeding under the skin

Ecchymosis – Widespread bleeding under the skin

Definition of Secondary Skin Lesions

These lesions result from external interference on the primary lesions such as
scratching, drying, etc. They include:

Scale - Dry and usually white.
Crust - Exudate on the skin that is often moist and yellowish or brow in
colour.
Lichenfication - Thickening of the epidermis from rubbing or scratching.
Is characterized by visible palpable thickening of the
skin and accentuated skin markings.



224
Fissure - Thin linear tear in the epidermis that usually indicates dry
skin.

5. Erosion - Tear in the epidermis that is wider than a fissure.

* 6. Ulcer - Defect in the skin that involves the epidermis as well as
a part or all of the dermis.

7. Atrophy - Loss of skin tissue. May involve the epidermis making the
skin to appear thin and wrinkled. When the dermis is
involved there is a detectable depression.

N.B: Photographs of these lesions are beyond the scope of this manual but can be
found in atlases on skin conditions

Common Childhood Skin Diseases
These include:

Dermatophyte infections of the skin
Bacterial skin infections
Viral infections
Scabies
Atopic eczema

I. Dermatophyte Skin Infections:

Definition:
Dermatophytes are filamentous fungi that possess enzymes to digest Keratin. They
infect the stratum corneum, hair and nails.

Nomenclature:
The nomenclature used in diagnosing dermatophyte skin infections is based on the part
of the body involved and the fact that the cause was earlier thought to be worms.
Hence the prefix, Tinea refers to worm (Latin) and the suffix denotes the part of the
body infected.

Following Are The Diseases:

Tinea capitis - Dematophyte infection of the scalp and the hair of the scalp.
scalp.
Tinea corporis - Infection of the body.
Tinea cruris - Infection of the legs and thighs.
Tinea pedis - Infection of the feet.
Tinea manuum - Infection of the hands.

T. Capitis is the most common dermatophyte infection.





225
Aetiology:
The fungi that cause dermatophyte infections are grouped in 3 genera namely
Trichophyton, Epidermophyton and Microspora.

Examples:
Trichophyton tonsurans, M. ondini, M. Canis. T. Verucosum and E. Flocosum.
Most common cause of T. Capitis is T. Tonsurans.

Transmission:

These infections are transmitted through sharing of towels, headwear, clothes,
beddings, washing basins, soaps and contact with infected person or animal.

Predisposing factors include: Overcrowding, low socioeconomic status, poor hygiene
and low immunity as in HIV infection.

Clinical Presentation:

These infections present in various ways depending on the type of infection. On the
scalp there may be papules, patches of hair loss, scales, and occipital
lymphadenopathy. On the body there will be patches with clear centre and active
advancing borders with scales. On the hands and feet there are scales, and interdigital
debris. All these may be accompanied with some itch.

Investigations:
Potassium Hydroxide (KOH) Test is used to diagnose these fungal infections. The
lesion is scrapped on the margins if it is on the scalp or the body and the test is done.
One sees hyphae.

2. Cultures: Fungal cultures are rarely required. The fungi are cultured on
Sabaraund Dextrose agar.

Treatment:

Generally, T. capitis and T. pedis are treated using oral antifungal drugs. Topical
agents are less effective. The other dermatophyte infections can be treated by either
oral or topical antifungal agents.

Griseofulvin tablets : 15 – 25mg/kg/day for 6-8 weeks. It is given once daily. This is the
standard drug for treatment of T. capitis.

Ketoconazole : 3.3 – 6mg/kg/day in children, maximum 200mg, OD for 28 days used in
the treatment of T. capitis, T. cruris and T. pedis.

Terbinafine – 250 mg OD for children over 40 kg, 125mg OD for children 20-40 mg and
62.5mg for children < 20 kg for 2-4 weeks. Used in the treatment of T. Capitis, T.
manuum and T. pedis.




226
Itraconazole – 3-5mg/kg/day for 4-6 weeks used in T. capitis.

Topical antifungal drugs are useful in T. corporis, T. cruris, T. manuum. They include
Whitfield’s, imidazoles, and tolfenate among many.


2. Bacterial skin infections

There are several skin diseases that are caused by bacterial and present with pustules
and blisters

A) Impetigo:
Definition: Superficial skin infection caused by gram positive bacterial usually S. aureus
This is very common in children.

Clinical features:
Starts as a single superficial lesion which is usually ignored by the parent until multiple
lesions occur. Other family members may be affected. The child may have atopic
eczema as well.
Most common lesion is a honey coloured crust (honeycomb appearance) without
ulcerations or erythema. Removal of the crust leaves an erosion
Lesions are mostly distributed on the face
Diagnosis is usually is usually clinical

Treatment
1. Topical antibiotics e.g. bacitracin (neosporins) and bactroban (mupirocin) are used for
small lesion. Systemic antibiotics are preferred where the lesions are large. Use a
penicillinase resistance antibiotics e.g. Dicloxacillin or oral erythromycin
Older children give 250mg qid for 7-10 days, younger child and infants give
30mg/kg/day in for divided doses for 7-10 days

B). Pyoderma (Ecthyma)
Definition – bacterial skin infection caused by group A, Beta haemolytic streptococcal
infection.
Clinical features:
Discrete vesicles which become pustular and covered by a crust
Removal of the crust exposes an ulcer. Lesions are surrounded with erythema and are
usually found in the lower extremities. Can occur after scratch or insect bites

Complications
Acute glomerulonephritis may follow streptococcal but not staphylococcal infection.

Treatment
As in impetigo but soak the lesions with either soap and water or an antiseptic before
applying the topical antibiotic. Systemic antibiotics are recommended because of the
renal complication





227
3. VIRAL INFECTIONS

With the advent of HIV/AIDS, there has been an increase in viral infections. Viral
infections present with vesicles, blisters and growths. They have no cure.
Aetiology
There are 3 DNA viral families that commonly cause skin diseases.
These are:
a) Herpes: Herpes simplex virus (HSV), Herpes zoster (shingles), and
Varicella zoster (chicken pox)
b) Parpovirus : Human papilloma virus
c) Pox: molluscum contagiosum

Pathogenesis
These viruses are transmitted through direct inoculation into the skin except for
varicella/zoster which is spread initially through respiratory system by inhalation. They
penetrate the epidermal cells where they replicate. Their location in the skin determines
the lesions produced

Warts and Molluscum contagiosum replicate in the keratinised cells (upper epidermis)
leading to hyperplasia and appear as growths

HSV replicates in hours, devastates the cells leading to lysis and death of the host cells
with formation of vesicle.

Herpes simplex
There are two types: HSV-1 which causes oral infection or perioral infection and HSV-2
causes genital infection. 90% of oral infections occur in children while most of the
genital infections are in post pubertal individuals after sexual exposure. Finding of
genital HSV in a young child suggests sexual abuse.

Clinical features
There is usually a prodromal itching and pain at the site of the lesion. This is followed by
appearance of vesicles that are grouped. The vesicles are mostly found in the perioral
region in children. Vesicles rupture, weep and crust. Healing occurs within one week.
Diagnosis is usually clinical.

Treatment
Acyclovir is the drug of choice. It is available as a topical and oral preparation.
1. Topical – 5% acyclovir ointment is used in the treatment of initial genital herpes and
localized peri-oral infection
2. Oral acyclovir is used in treating primary and recurrent infections
3. Intravenous Acyclovir is used in severe infections in immunocompromised patients

Herpes Zoster (Shingles)
Definition – these are intra-epidermal, vesicular eruption along the dermatomes.
Cancer and AIDS patients have higher incidence of 8-25%
Incidence – 10-20% of individuals develop it in their life time. It is common above the
age of 50 years. Recurrence is rare



228
Clinical features
There is a prodromal period when the child will have pain and itching before eruption.
Vesicles appear along a dermatome and have an erythematous base. They are usually
these are unilateral but may be bilateral in HIV infected patients
Diagnosis is usually clinical

Treatment
1. Analgesics: the choice of analgesic has to be commensurate with the degree of pain
2. Acyclovir: dosage of 10mg/kg every 8 hours intravenously for 7-10 days.
3. Acyclovir 800mg 5 times a day for 7-10 days in adults.

Varicella zoster
Definition: acute highly contagious intra-epidermal vesicular eruption caused by
varicellar zoster virus.
Incidence: 90% of cases occur before 10 years of age.

Clinical features
The incubation period of 2-3 weeks is followed by a prodromal stage which lasts 2-3
days. Presents with: chills, fever, malaise, headache, sore throat, anorexia, and cough
but these are often minimal. An intensely itchy rash appears. All types of lesions are
seen at the same time. They include: macules, vesicles, papules, pustules and crusts
Diagnosis: usually clinical.

Treatment
A) Supportive.
1)) antihistamines
2) calamine lotion
3) paracetamol( do not use aspirin due to possibility of Rye’s syndrome)
B) Specific treatment

Acyclovir is not indicated in immuno-competent children.
IV acyclovir is used in immunosuppressed children, at 500mg/m
2

Varicella zoster immunoglobulin (VZIG) is useful in immuno-deficient children

Prevention - Live attenuated virus vaccine

Note: In difficult to diagnose varicellar/zoster cases a Tzanck test can be done. Tzanck
test reveals multinucleated giant cells.

Molluscum Contagiosum
Definition – Viral infection of epidermal cell caused by a pox virus
Common in childhood
Presents with papules 2-5mm wide dome shaped umbilicated single or grouped on the
trunk, face and extremities. May be generalized in immunosuppressed children
Diagnosis is usually clinical.

Treatment – curettage, or cryotherapy, or Cantheridine




229
Warts
Definition. These are benign growth caused by infection the epidermal cells with
papilloma viruses
Predisposing factors include:
HIV infection
Renal transplant
Use of steroid
And use of cytotoxic drug
Ano-genital occurrence in children suggests sexual abuse
Clinically appear as:

1. Verruca vulgaris (common wart) which may be a papule or nodule with corrugated
surface that is flesh coloured and firm with a black dot. Distributed on fingers and hands

2. Flat wart flesh coloured and 2 – 5 mm wide

3. Plantar Wart single and painful found of the plantar surface of the foot

4, Condylomata acuminata (venereal wart)
Lesions is a papule or plaque that is soft, moist sessile or pedanculated usually
destructive, and painful
Distribution on the rectum, perineum, vagina, inguinal folds, external genitalia and
urethra

Treatment options include:
cryotherapy
electrodessication
curettage
laser
surgical excision

Venereal Warts – podophyllotoxin

Common Warts –
a) 17% Salicylic acid ointment
b) 17% Salicylic acid in polyacrylic vehicle
c) Cantheridine
d) cryotherapy

Flat warts
a) Retin A
b) 5% salicylic acid ointment

Plantar warts
10% formaldehyde
Salicylic acid plaster





230
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 4
th
day.

Single application of 1% lindane lotion or 5% permethrin cream at bed-time and washed
off in the morning is also recommended. This may be repeated after 1 week. Lindane
should be avoided in infants. The agents are applied on the head as well.

5. ATOPIC DERMATITIS (ECZEMA)

Definition:
Eczema: Greek word that means “to boil over”.
Atopic (Eczema) dermatitis is a chronic, pruritic condition of the skin that is associated
with personal or family history of atopic diseases such as bronchial asthma and /or
allergic rhinitis.

Incidence: not well documented especially in Africa





231
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 in
2
/
3
of
their family members. Food allergy – occurs in 10% of the patients. Contact allergy –
occurs in 10% of the patients.
Mode of presentation:
Acute - presents with papules and vesicles.

Subacute- papules, vesicles and some lichenification

Chronic - lichenification
Diagnosis is usually made on clinical grounds

Therapy:
Management is usually difficult because of the chronic nature of the disease
Aim of treatment is to reduce inflammation and itching. The mainstay of treatment is
topical steroids and systemic antihistamines. Initiate treatment with a potent steroid and
taper down to a less potent one.
Use ointments for dry lesions, creams for wet lesions, and lotions where there is hair.
Topical Steroid Therapy:
Topical steroids are classified from the most potent to the least potent (Class I to class
VII) respectively. Example class I is betamethasone and Class VII is hydrocortisone.
Class I should be used for a maximum of 14 days (where applicable) and changed to a
less potent one.
Avoid class I steroids in:
Children aged less than 5 years.
Face
Groin of all age groups
Axillae
Antihistamine Therapy:
There are sedating and non-sedating antihistamines.
Sedating antihistamines are more effective in controlling the itch than non-sedating.
Example of sedating antihistamine is chlorpheniramine.
Example of non-sedating is loratadine.
Antibiotic Therapy:
Antibiotics are used in cases where the lesions are weeping. If the lesions are localized
then topical antibiotics such as mupirocin are used. If it is generalized then oral
antibiotic effective against S. aureus such as cloxacillin is used.
Atopic Advice:
Children with this disease should be advised to:
Bath in warm water using medicated soap.
Avoid woolen fabrics instead use cotton clothes and beddings.
Moisturize the skin at least twice a day. Vaseline pure petroleum jelly is commonly
recommended.





232
RECOMMENDED READING AND REFERENCES:

Donald P. Lookingbill and James G. Marks, Principles of Dermatology; Second Edition.
WB Sanders Company, Philadelphia.

Sidney Hurwitz Clinical Pediatric Dermatology WB Sanders, Company, Philadelphia;
Second Edition.

S.O. Ayaya, K.K. Kamar, R. Kakai. Aetiology of Tinea Capitis in School Children, EAMJ
(78) Oct 2001, pp 531 – 535.

Okafur J.I. and Agbubaerulehe A.K. Dematophytoses among school children in Aba,
Abia State, Nigeria and some physiological studies on isolated aetiological agents. J.
Common Dis 1998 30; 44 – 9.

Figureson J.I., Hawravek T, Abraham A, and Hay R.J.,Tinea capitis in south Western
Ethiopia: A study of risk factors for infection and carriage . Int. J. Dematol. 1997 361 :
661 – 6.

































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CHAPTER 19

ESSENTIAL DRUGS AND RATIONAL USE OF ANTIBIOTICS

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


INTRODUCTION
No discussion of health services is possible without consideration of budgeting. Where
funds are limited, as is the case in most economically less developed countries,
priorities must be set so that essential drugs are always available for those needing
them. Thus provision of essential drugs is a fundamental element of any comprehensive
primary health care programme. Getting essential drugs to people under a well
organized supply system, proper prescription by the health personnel and appropriate
drug use by the consumer are all essential ingredients of the Essential Drug
Programme. It is therefore important for the student of medicine to understand what
essential drugs are, their pharmacology, dosage and indications.

Essential drugs may be defined as cost-effective drugs with proven efficacy for which
adequate standards of quality have been established and which meet the health needs
of the majority of the population. These are discussed in Section A of this chapter.
Section B deals with rational use of antibiotics.

OBJECTIVES
At the end of this chapter, the student should be able to:
- Explain the concept of essential drugs;
- Outline criteria for choosing essential drugs;
- List essential drugs for a defined community;
- Discuss guidelines for rational prescribing of antibiotics.

LEARNING ACTIVITIES
To aid the student in learning about the operative essential drugs in a particular health
locality visits to at least two health centers (He) considered representative of the area
are recommended. At each of these health facilities the student should engage in the
activities listed below:

Be familiar with the essential drugs list in your country;

Correlate the essential drugs available in the HC to the pattern of disease in the area;
- Follow the steps of drugs procurement, storage, distribution and their use in that
He.
- Use these findings to assess the performance of the essential drugs programme
for the area.
- Provide immediate feedback on your findings to the HC staff.
- Prepare a written report summarizing your findings and conclusions.
SECTION A: THE CONCEPT OF ESSENTIAL DRUGS



234

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

Any selection of essential drugs must therefore depend on the following key
criteria, namely:

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

In addition, selection of specific drugs should depend on:

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

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

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

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

Typically a very short list is compiled for community health workers while the
most comprehensive lists are reserved for large urban and regional hospitals.

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



235
rehydration salt sachets; and tetracycline eye ointment or drops.

Text box:

WHO recommends the following for various levels of health facilities:
6-15 drugs at a village health post
5 – 20 drugs at a dispensary
20 – 45 drugs at a health center
100 – 120 drugs at a district hospital
> 250 drugs at a tertiary hospital

Effecting the concept of essential drugs can have certain advantages, including
economic saving. In addition ;
- Storage and distribution of drugs becomes easier to manage.
- A careful and rational selection of drugs is made on the basis of real needs.
- Correct dosage is easier to remember, thus increasing safety of drug usage.
- There is less drug wastage.
- Helps to obtain reliable data on drug consumption.
- Favorable influence on the practices of training centers in therapeutics and
general drug management can be achieved more easily.
Before establishing essential drug programmes, there is need for selecting essential
drugs using WHO criteria as a guide. The steps involved in establishing essential drug
programme can be summarized as follows:
Formulation of health policies on identification of therapeutic needs;
- Drug identification, procurement and storage;
- Training of personnel;
- Information and education,
- Quality control of drugs;
- Supervision, monitoring and evaluation,
- Financial support.
At country level there are good reasons for establishing an essential drugs programme
as this can avoid:
- Unsatisfactory procurement procedures and erratic ordering of drugs frequently
resulting in serious drug stock outs and expensive purchases.
- Unsupervised importation of drugs or raw materials for their production.
- Acute shortage of foreign currency to import drugs or their raw materials.
- Under utilization of the local drug production capacity.
- Poor drug storage and drug distribution practices.
- Rapid expansion of health services without a increase in drugs supply capacity.
- Unsatisfactory use of drugs both by health workers and the public.






236
Organization of an Essential Drug Programme
An essential drug programme is a comprehensive and complex system of drug
production, procurement, packaging, distribution and use for any country. In order to
execute it effectively there is need for proper organization. An organization structure
consisting of four levels can be envisaged:
National Level
At the national level there is an essential drugs unit or department in the
Ministry of Health. While functions at this level vary from country to country,
they include planning, acquisition of funds, regulatory control, drug procurement
and distribution, training and liaison between ministries.

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

Health Centre/Dispensary Levels

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

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

Drug Procurement is the most important activity in implementing the essential drug
programme. It involves estimation of drug quantities. There are three different ways to
estimate drug needs:
- Population-based estimation calculates the theoretical needs of a given
population based on the burden and pattern of disease in the community.
Although this is probably the ideal method, it is not attainable in the short time
especially where the health service do not cover the entire population or
community;
- Service based estimation depends on health service statistics only and considers
patients who come for care. It enables us establish objectives so as to avoid
stock outs. This implies that health services have been in existence for some
time and past records of diseases treated and drugs prescribed are available
and reliable.
- Consumption-based estimation is the most commonly used method. It requires a
system that provides satisfactory information on monthly drug consumption and
stock level in health-care units throughout the year. However, this method can
under-estimates true demands because of lack of information on diseases
treated.



237

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

Managerial and other problems

Notwithstanding the aforegoing, observation of the situation on the ground soon
reveals problems that threaten the successful implementation of the essential drugs
programme. These include:
- Lack of funds;
- Erratic procurement and supply;
- poor record keeping;
- Poor supervision;
- poor quality control; and
- misappropriation of funds and drugs.
All such, problems bust be anticipated and vigorously dealt with, if the noble aims of
this programme are to be achieved.

Section B1: Better medicines for children: Recent progress

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



238
century after general awareness of the challenge in optimal pediatric pharmacotherapy
was awakened by the chloramphenicol misadventures of the 1950s.
We have now reached a point at which there are an estimated 5 million deaths annually
among children 5 years or younger that could be prevented by effective, affordable,
accessible drug therapy.
The approval and promulgation of a WHO list of essential drugs for children (EMLc) is a
step forward
(2)
; a necessary but not sufficient condition for the improvement of therapy-
related outcomes in children. Now that this critical first step has been taken it is
important to focus attention on the need for international regulatory harmonization and
for the urgent need to develop and test appropriate new pediatric formulations. More
attention must be paid to region-specific needs identified through formal needs
assessments.

Key actions:
(3)


1. closing the know-do gap: This can be achieved in the context of many common
childhood diseases through the development and dissemination of best practice
guidelines.

2. addressing absolute gaps in knowledge: This can be achieved through research
focused on orphan diseases and on a concerted effort to achieve improved labeling of
drugs for pediatric use.

3. promoting safe medications practice in hospital and community child health care
settings

4. assigning priority to the development of child-friendly formulations and fixed dose
combinations

5. emphasizing drug therapy as a key tool for reduction in childhood mortality,
particularly in newborn treatment settings, and in management of communicable
diseases, including ARI and diarrhea

6. improving access to medications through better supply chain management

Section B2. Environment for paediatric prescribing

As it is not possible to know everything necessary about all the drugs available,
experienced child health clinicians tend to use a few important or representative
preparations. Nevertheless, whenever a drug is to be prescribed for a patient, the doctor
should always consider the following key points:

1. Is the drug really necessary?
Does the patient need any drug at all? Is the drug being given to relieve symptoms, to
treat an underlying disease, or to make the patient feel something is being done? If so,
is the drug prescribed the most suitable for that condition? What side effects may the
patient suffer? Do the possible benefits outweigh the possible risks? And lastly, how
may the drug interact with other drugs the patient is receiving?



239

2. Is the cost of treatment acceptable?
The cost of some very similar drugs can vary by a factor of up to 200. Since someone
must pay, consideration of cost is only rational. Thus the cheapest effective agent
should be chosen over more expensive medications. This will leave money available for
other needs such as some expensive but essential drugs.

3.Is confusion caused by use of proprietary names?
Often one drug is marketed under several proprietary (trade) names. This may cause
confusion in prescribing. Of greater importance, however, is the fact that drugs
marketed using their proprietary names are also more expensive. For these reasons,
the generic (official) name should be used when prescribing.

4.Will the product have adequate shelf life in tropical climates?
As stated above, most drugs are manufactured in the temperate climates of
economically developed countries. The printed expiry dates for these drugs are
therefore calculated for these climates. Thus when the same drugs are stored in tropical
climates the shelf life may be less than half of that in their countries of manufacture.
Patients and families need to be educated on this important fact.

5. Has the new drug been appropriately evaluated in children?
There is an unfortunate tendency to discard old and well tested drugs in favour of new
preparations. This is often done without critical appraisal of marketing claims for the
new drug, its cost, or cost-effectiveness. Many references quoted by pharmaceutical
companies in favour of their drugs are reports of uncontrolled or flawed trials where the
company may have sponsored the trial. A good trial should involve adequate numbers
and should be randomized and blind (double blind if possible). An established (gold)
standard drug should be compared with the new drug and not a placebo to establish
relative efficacy. Lastly, the results of the trial should have been reproduced by others
and, particularly, in comparable populations. Anecdotal reports are unsatisfactory and
unreliable.

6. Have families been adequately engaged in a therapeutic decision?
Treatment failure can result when families do not understand how drugs should be
used. Multiple drugs can cause confusion, even among educated patients and families.
Worse, when drugs are not packaged and stored properly in the home, they can be
ingested by children and cause poisoning. For these reasons, and in order to minimize
the risk of drug interactions, the doctor or pharmacy staff should take time to provide
patents and families with key information on the drug’s dose, regimen, home storage,
and side effects.

7. Has the dosage been correctly calculated?
Because all children, and especially neonates, differ from adults in their response to
drugs, and children of the same age can vary considerably in body weight, paediatric
dosages should be calculated according to body weight. Using Body Surface Area
(BSA) provides more accurate dosages but it is less practical. However, when
paediatric dosages are not available for a given preparation, they may be estimated by



240
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 = 0.45m
2
3600

N.B. Both formulae require square root sign. Formula is taken from the WHO pocket
book of Hospital care for Children, page 325.
Section B3. Rational antibiotic use: common infectious conditions

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

Table 1. Infectious Diseases

Disease Drugs and dosage Comments
Anthrax Benzylpenicillin 50,000
units/kg/dose 1M in ~
divided doses for 5
days; age> 8 years
tetracycline 250 mg qid
for 5 days


Tetanus Benzylpenicillin
50,000U /kg/dose
daily in divided
doses;

plus tetanus
antitoxin 10,000U
1M once



If serum is given, start with
test dose and ensure
epinephrine I: 1000 is
drawn up and ready.
Diazepam should be used
to control spasms and
patients should always be
immunized. Surgical
debridement may be
indicated.

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


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



241

Older children > 13
years ciprofloxacin
Opthalmia
neonatorum

Gonococcal





C.trachomatis



IV ceftriaxone
50mg/kg one dose




Tetracycline eye
ointment applied 3-
4 time daily

Plus

erythromycin
50mg/kg daily in 3
divided doses.



Saline irrigation

Table 2. Respiratory Conditions

Upper
respiratory
tract infection
(common cold)
Usually viral, so no
treatment

Mucoid discharge
often accompanies
common cold and is
not an indication for
antibiotic use.
Acute sinusitis
Amoxicillin 15mg/kg/dose
3 times a day for 7 – 10
days



Acute tonsillitis

Phenoxymethyl penicillin
30 mg/kg orally in divided
doses for 5 days or
amoxicillin 15 mg/kg/dose
3 times a day for 10 days

Erythromycin 12.5
mg/kg/dose 4 times a day
for children allergic to
penicillin


The principal indication for
antibiotic use is the primary
prevention of acute
rheumatic fever

Broad spectrum antibiotics
are no more effective and
increase the risk of
developing resistant
organisms
Acute otitis
media
amoxicillin 15
mg/kg/dose 3 times a
day for 10 days

or

Decongestants and
antihistamines are not useful
in acute otitis media





242
cotrimoxazole 24 -30
mg/ kg/ dose every 12
hours, all for 5-10 days.

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

Croup

Usually viral so
antibiotics are not
indicated
For moderate to severe
Croup oral or iv
Dexamethasone 0.6
mg/kg/dose single dose

Prednisone 1-2 mg/kg with
other supportive including
oxygen

Pneumonia
Mild pneumonia
(outpatient)

Oral amoxicillin 15
mg/kg/dose /day 3 times
a day

Or

cotrimoxazole 24-30
mg/kg every 12 hours

Duration: 7 to 10 days


Severe Pneumonia

benzyl penicillin 50 000
units/kg every 6 hours





Chloramphenicol 25
mg/kg/dose every 6 hrs

OR



If evidence of
staphylococcus including
pustules :

cloxacillin 50-100
mg/kg/day iv or im AND
Cough medications are not
beneficial in pneumonia and
some may be harmful












For immunocompromised
children including HIV and
severe malnutrition add plus
gentamicin (7.5 mg/kg once
daily)


Do not give chloramphenicol
to premature neonates.




If empyema is
confirmed under
water seal drainage



243
gentamicin 7.5 mg/kg iv
once daily


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



Pneumocystis
jirovecci
pneumonia
(PCP)
Intravenous
Cotrimoxazole 24 mg
/kg/dose given every 6
hours for 21 days.


Give the same dose orally
if IV preparation not
available
Add prednisone 2 mg/kg/day
for 7 days if child is in
severe respiratory distress

Prophylaxis: Lifelong
Daily cotrimoxazole 24
mg/kg once daily


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


Useful in aborting infection
only if early during the
catarrhal stage; no effect on
course if given later.

Salbutamol and steroids
may be useful in severe
cases

Pulmonary
tuberculosis
Intensive phase (2
months)

Isoniazid 5 mg/kg /day
Rifampicin 10 mg/kg /day ,
pyrazinamide 25
mg/kg/day

Once daily

Continuation phase:4
months
Isoniazid 5 mg/kg /day
and Rifampicin 10 mg/kg
/day



Table 3.
Gastrointestinal
disease

Cholera Erythromycin 12.5 mg/kg
/dose 4 times daily for 3
days
Fluids and potassium are
essential to the treatment;

Antibiotic use shortens the



244

Or
Sulfamethoxazole 20
mg/kg and trimethoprim 4
mg/kg daily in 2 divided
doses

Above 8 yr: doxycycline

shedding of vibrio cholerae


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

Use local sensitivity pattern
As second line ceftriaxone
80mg/kg once daily for 5
days
Dysentery
amoebic
Metronidazole 7.5
mg/kg/dose 3 times a day
for 7 days

add zinc 20 mg once daily
(dose)


Table 4.
Genitourinary
disease

Acute UTI
Cotrimoxazole 24
mg/kg/dose twice a day
for 7 days


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

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



Encourage fluids. Consider
if underlying pathology
especially in children <
5years.

In cases of resistance (poor
response) Cephalexin 12.5
mg/kg/dose 4 times for 7-
10 days
Pyelonephritis

Gentamicin 7.5 mg
/kg/day for 7- 10 days

Ceftriaxone 50-75 mg/kg
/dose once daily for 7
days




Caution: use of
aminoglycosides weighed
against potential for renal
compromise



245
Recurrent UTI
Suppressive therapy in
children with trimethoprim
2 mg/kg daily and
sulphamethoxazole 10
mg/kg daily in 2 divided
doses

Or

Nitrofurantoin 2
mg/kg/dose 3 times a day


Investigate urinary tract to
rule out anatomic
abnormality











Table 5.
Musculoskeletal
Pyomyositis Surgical drainage.

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


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



Acute
osteomyelitis
Cloxacillin 25 mg//kg/dose
4 times a day for 4-6
weeks
In children with sickle cell
disease a possible cause is
Salmonella. Add
chloramphenicol 25
mg/kg/dose 4 times a day

Avoid prolonged treatment
with chloramphenicol

Chronic
osteomyelitis
Surgery is the mainstay of
management


Septic arthritis Same as acute
osteomyelitis
Surgical drainage


Table 6. Neurologic
conditions

Meningitis
unknown
organism
Choramphenicol 25
mg/kg/dose 4 times a day
for 10 days .

AND
Reserve antibiotics for 2
nd

line: ceftriaxone 100
mg/kg /day in 2 divided
doses or cefotaxime 100
mg/kg/day in two divided



246

Benzylpenicillin
75,000/kg/dose 4 times a
day for 10 days

For neonates with
meningitis:

Gentamicin 7.5 mg/kg/
once daily for 14 -21
days

AND

Ampicillin 50mg /kg/dose
twice a day for 7 days
then 50mg/kg/dose 3
times a day for 7-14 days
(total duration 14 to 21
days)

doses



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


2nd line : ceftriaxone 100
mg/kg /day for 7-10 days
Meningococcal Benzylpenicillin
100,000iu/kg/dose 4 times
a day 5-7 days

Prophylaxis to contacts:
ciprofloxacin or
cotrimoxazole

Resistance to penicillin is
rare
H. influenzae
type B
Chloramphenicol 25
mg/kg/dose 4 times a
day for 7-10 days


2
nd
line ceftriaxone
100mg/kg once daily for 7-
10 days

Incidence reduced in those
settings where routine
childhood immunization is
practiced
Gram negative
rods (E. coli)

Chloramphenicol 25
mg/kg/dose 4 times a day

or

Ceftriaxone 100 mg /kg
/day in 1- 2 divided doses
or cefotaxime and
gentamicin.

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




247

Duration: minimum 14
days up to 21 days

Cryptococcal
meningitis
Induction with
amphotericin B 0.7-1
mg/kg/day for 2 weeks

Followed by:

Daily: 6 mg/kg/dose once
daily at least 10-12
weeks

Then
Maintain fluconazole
3mg/kg/day
Prophylaxis oral fluconazole
Brain abscess Metronidazole 7.5 mg/kg
/dose 3 times a day

PLUS

Cloxacillin 25mg/kg/dose
4 times a day

PLUS

Gentamicin 7.5mg/kg
once daily

Duration: 6 -8 weeks

Surgical aspiration or
excision may be indicated

Concept of Reserve antimicrobials
Pathogens that are resistant to all normally appropriate essential drugs are increasingly
emerging in various countries or regions. In such instances a reserve antimicrobial is
needed. A reserve antimicrobial is an antimicrobial that is useful for a wide range of
infections but, because of the need to reduce the risk of development of resistance and
because of its relatively high cost, it is not recommended for unrestricted (widespread)
use.
Examples:
Resistance to beta-lactam antimicrobials is generally due to the production of beta-
lactamases in staphylococci, enterobacteria, Haemophilus spp., gonococci and
Pseudomonas spp. In several of these organisms and in others such as pneumococci
and enterococci, other non-enzymatic mechanisms are also involved. Many new beta-
lactam antimicrobials have appeared and are included in the model list as reserve
antimicrobials. In order to preserve the activity of these antimicrobials it is
recommended that these agents are used only where rates of resistance to all normally



248
appropriate essential drugs are high or for specific indications, as listed below. a. beta-
lactimase inhibitor amoxicillin + clavulanic acid is active against many of the enzymes
produced by enterobacteria . A specific indication for its use is in polymicrobial
infections related to surgical conditions of the intestinal tract and female genital tract.
Amoxicillin remains active against many common bacteria such as -haemolytic
streptococci and a high proportion of Haemophilus influenzae strains in many countries.
The levels of penicillin resistance in Streptococcus pneumoniae do not at this time
justify replacement of the use of penicillins in the treatment of respiratory tract
infections.
b. Many parenteral cephalosporins active against Gram-negative bacteria are now
available and are widely used for the treatment of infection. The model essential drug
list now includes ceftriaxone as a reserve antimicrobial for the treatment of meningitis
due to Streptococcus pneumoniae in areas where penicillin resistance is found.
Cefuroxime is not as effective as ceftriaxone or cefotaxime in pneumococcal meningitis.
c. Ceftazidime is included in the essential drugs list because it is the most active
cephalosporin against Pseudomonas aeruginosa. It is suggested that it should be used
when the prevalence of resistance to gentamicin is high.
d. Imipenem is a broad-spectrum -lactam antimicrobial included as a reserve agent
for the treatment of Acinetobacter spp. infection and Pseudomonas spp. resistant to all
normally appropriate antimicrobials. Such resistant organisms are usually only found in
tertiary care hospitals and in particular in intensive care units where antimicrobial usage
is high.
e. Ciprofloxacin is a member of the fluoroquinolone family of antimicrobials. Although
this is now listed as an essential drug, the comparative costs of alternative broad-
spectrum products will be an important determinant of selection. Ciprofloxacin and
certain other fluoroquinolones may still be considered of value as reserve agents. Their
use may need to be restricted to the following circumstances (also note that in children
below 13 years fluoroquinolones may lead to arthropathy and therefore benefits must
be weighed against the potential risk):
For typhoid fever and other systemic salmonella infections where there are strains of
Salmonella resistant to chloramphenicol, amoxicillin and trimethoprim +
sulfamethoxazole.
For severe shigellosis where Shigella spp. strains exist that are resistant to ampicillin,
chloramphenicol, trimethoprim + sulfamethoxazole, tetracyclines and nalidixic acid.
For gonorrhoea and chancroid, as alternatives to cefalosporins, when oral
administration is appropriate.
For hospital-acquired infections due to Gram-negative bacilli, including Escherichia
coli, Klebsiella spp. and Pseudomonas aeruginosa, that are resistant to essential drugs
such as amoxicillin, chloramphenicol and gentamicin.



249
Methicillin-resistant Staphylococcus aureus strains are usually resistant to all -lactam
antimicrobials and also to unrelated drugs such as erythromycin, clindamycin,
chloramphenicol, the tetracyclines and the aminoglycosides. The only effective reserve
drug for infections due to these multiresistant organisms is vancomycin, which is
expensive and must be administered intravenously.
Need for surveillance of resistance
Knowledge of prevailing susceptibility patterns is vital to the selection and use of
antimicrobials and to the development of appropriate prescribing policies. Without these
data the health of seriously ill patients could be jeopardized. Knowledge of susceptibility
patterns should come from proper laboratory investigations. Decisions on drug use
should be taken on the basis of standardized therapeutic efficacy testing.
To minimize the development of antibiotics resistance the prescription of antibiotics
should satisfy the following:-

There should be clear indication for antibiotics use. All bacteriological specimens,
should be taken before start of therapy;
- In general for all antibiotics, prescribe for at least five days initially;
- Change of antibiotics should be done with guidance from the laboratory;

It is safer to add than to replace one antibiotic for another especially in an acutely ill
patients where the nature of the infecting organism is not known. Always administer
antibiotics in correct dosage for the right length of time:
- Clinical progress of the patient should be reviewed at regular intervals;
- Topical use of antibiotics should be avoided except in specific defined
clinical conditions e.g. eye preparations;
- Preference for bactericidal antibiotics with a narrow spectrum and low toxicity.























250
REFERENCES

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

7. Handbook on Paediatric AIDS in Africa by the Network for the Care of Children
Affected by AIDS 2006.

8. British National Formulary, number 25; March 1993





























251
CHAPTER 20

CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCES

Nimrod O Bwibo and Mary Shilalukey Ngoma

INTRODUCTION
The children in especially difficult circumstances – (CEDC) – are children whose basic
needs such as shelter, food, education, health care and security are not met due to
prevailing adverse conditions in a community. Group or individual acts may cause harm
to children and/or prevent them from realizing normal growth and development causing
them to be in difficult circumstances.

High rate of population growth and in some African countries and increasing
urbanization in a time of economic stress is breaking down families as well as
community support systems for disadvantaged children. Consequently, large and
growing numbers of children end up in especially difficult circumstances.

OBJECTIVES
At the end of this chapter the learner shall be able to:
Define children in difficult circumstances
Discuss the underlying causes
List the categories of CEDC
Discuss psychosocial problems among CEDC
Describe the main features of the various categories
Describe health management of children in emergency situations
Provide guidelines for prevention of the problem

LEARNING ACTIVITIES
Visit streets of big towns and find out if there are street children (families)
Obtain and read a copy of the convention of rights of the child
Find out how your country has ratified the convention (is there a children’s act that
includes the rights of the child?)
During the paediatric clerkship find out if there are children admitted because of child
abuse
Find out if there are organizations that address the rights of children in your country
Find out if your government has ways of addressing the problems of CEDC
Have a group discussion on possible interventions that would improve the welfare of
children in these situations

The child is defined as a person under 18 years of age. Though in some counties take
the cut off at 16 years. Often people talk of orphans and vulnerable children.
The definition of an orphan is a child under the age of 18 years who has lost a mother,
father, or both parents due to death. An orphan can be further defined as a double
orphan if the child has lost both parents, whereas a maternal orphan and paternal
orphan is defined as the loss of a mother or father respectively.




252
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



253
relatives do not move in, to assist their orphaned children, thus leaving them to fend for
themselves. Children who live without the guidance and protection of an adult care
givers are often more vulnerable and at risk of becoming victims of violence,
exploitation, trafficking, discrimination, early marriage and other abuses.

Some of African traditional cultural values give rise to child abuse, which leads to
children having babies when they are not physically and psychologically mature for the
responsibilities of being mothers. Taboo babies arising from traditional cultural practices
in some communities are unaccepted to their biological parents and are thus exposed to
all sorts of abuses especially abandonment.

Parents facing economic constraints may engage in illegal activities and my end up
serving custodial sentences. During which time they leave their children without support.
Mothers who go into prison may be allowed to go with their children who are aged
below four years. At least such mothers continue to take care those children but in
abnormal environment.

By and large, traditional land tenure and inheritance laws in many African cultures tend
not to provide for women to inherit land and property. So unmarried mothers looking for
neutral areas to settle end up in urban centres. Also involved in the migration to towns
are the youth – both young men and women seeking employment. More often than not,
the anticipated employment is not forthcoming and like the unmarried mothers often
engage in petty trades that cannot maintain their families. Their children are forced into
the streets, into petty trades as child labourers or even child prostitutes.

Whole families may be rendered landless due to land pressure and transactions. They
become squatters and their children lack proper basic amenities. Majority of them end
up as child labourers or members of other groups of CEDC.

Parents suffering from HIV/AIDS are now contributing to a large and increasing
numbers of CEDC. Unlike victims of other terminal illnesses, parents with HIV/AIDS
often die leaving their children not only without support but also stigmatized while others
may be HIV infected. An important emotional problem is space to grieve, as children
are often denied the grieving process, which is an important component of the
bereavement process.

Children with disabilities tend to be neglected and as result suffer from malnutrition,
poor health and are often victims of abuse and neglect.

Children in Conflict and Emergencies:
Many children within Africa have been affected by volatile political situations that have
contributed to an exodus of refugee children into neighbouring countries or internally
displaced families. These children end up in crowded refugee camps.
In a study in Zambia, a number of complex health issues were observed at refugee
settlements in remote parts of the country. Refugee children developed malnutrition and
micronutrient deficiency states during flight. This may not be documented and some
children die, during flight, without featuring in the statistics. About 20 % of refugee
children were malnourished during the early period of arrival to camp.



254
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.



255
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:



256

Lack of relevant and properly trained personnel to handle CEDC in both government
and NGOs at all levels.
Inadequate logistical support and lack of community – based preventive rehabilitation
programmes.
Lack of effective co-ordination amongst agencies working with target groups leading to
duplication of projects.
Overstretched facilities in terms of accommodation as well as in manpower and financial
resources.
Mixing of disciplines with protection cases in approved school due to lack of alternative
care for such cases.
Presence of undeserving cases in rehabilitative institutions meant for CEDC. This calls
for professional assessment of subjects prior to admission.
Lack of effective after –care following services foe graduates of rehabilitation centres.

CONCLUSIONS
It is crystal clear from the foregoing that CEDC is an existing problem.
It has identified both internationally and nationally. This calls foe effective policy
guidelines to safeguard the children’s rights with a view of arresting the existing
problems and as far as possible preventing the same from recurring.

The International Convention on the Rights of the Child is a blue print into solving the
problem of CEDC. The aims and objective of the Conventions can only be attained for
the African child in especially difficult circumstances by both the Government and
NGOs. This requires immediate Action.
Exercise 1
Stop to reflect on the situation of orphans and vulnerable children in your country. Form
small groups to discuss the following:
1. Who is an orphan?
2. Who are vulnerable children?
3. What are the causes associated with being orphaned and vulnerable?
Exercise 2
What are the health needs of children in refugee circumstances?
1. In small groups or individually itemize these health needs?

2. How can plans be made to take care of the health needs?

3. Plan to visit a refugee situation near you. What is different between your healthcare
system and that of refugee children?
What needs to improve in the service provision?

Exercise 3

Are there other children on the margins of society in your locality?
1. Who are they?
2. How can their welfare be addressed?
3. Form small groups, visit and discuss plans for intervention and how to harness
assistance.



257
REFERENCES

The Convention on the Rights of the child New York UNICEF 1989

UNAIDS/UNICEF/USAID, 2004; UNAIDS/WHO, 2007

http://www.Avert.org; UNAIDS/WHO, 2006.

Skinner, Tsheko, Mtero-Munyati, Segwabe, Chibatamoto, Mfecane et al., 2004; Smart,
2003).

Children on the Brink Report (UNAIDS/UNICEF/USAID, 2004)
Altman, 1994; Pizzo & Wilfret, 1995; UNAIDS/UNICEF/USAID, 2004.

Shilalukey Ngoma, Mudenda C. Ngoma J Lessons learnt in health during influx of
refugees into Zambia

Note: Website of the United Nations and other agencies mentioned in the chapter can
give invaluable references.
































258
CHAPTER 21

HEALTH EDUCATION, COMMUNICATION SKILLS AND COUNSELLING

Esther D. Mwaikambo, Amos Odiit

INTRODUCTION
Health education is one of the core Primary Health Care strategies. It is a process of
helping change people’s behaviour in a way that will make their health and that of their
families and the community better. It is concerned with helping people take greater
responsibility for protection and promotion of their own health through provision of
correct information and modification of the existing inappropriate attitudes and practices
in respect to prevention, promotion, curative and rehabilitative care. It is also aimed at
promoting healthy lifestyles of the individual and the community. In the context of child
health, health education should aim at preventing common illnesses such as: diarrhoeal
diseases, malnutrition, acute respiratory infections, malaria, whooping cough, measles,
tuberculosis and acquired immune deficiency syndrome. Health workers therefore need
to develop proper attitudes, adequate knowledge and skills that will enable them provide
health education at various service delivery settings.

OBJECTIVES
At the end of this chapter the student will be able to:

Define health education;
Explain the factors which determine an individual’s behaviour;
Explain the determinants of behavioural change;
Describe the role of health workers in the provision of health education to communities;
Describe effective communication process and effective education methods;
List basic skills needed by all health workers to impart health education effectively;
Identify the health education needs of different categories of patients and communities
Describe the principles of counselling
Describe the process of planning, organizing, implementing and evaluating a health
education programmes in a community.

LEARNING ACTVITIES
Participate in a group of health workers discussing basic health education skills needed
by all PHC workers and prepare a report.
Visit a child welfare clinic and determine the incidence of missed opportunities for health
education.
Prepare specific health education messages aimed at preventing diarrhoeal diseases,
malnutrition, and acute respiratory infections, malaria and measles.
Participate in a health education session in a child welfare centre.
Visit the national, regional or district health education unit and describe the different
communication and education media used for the promotion of health in your country.







259
DETERMINANTS OF BEHAVIOURAL CHANGE:

The effects of health education efforts are strongly influenced by the individual’s cultural
beliefs, attitudes and values. Clear understanding of these attributes and their
consideration in preparing and giving of health education will have a positive influence
on the impact of the program. For instance, in most African communities children are
denied certain high protein and energy foods like eggs and fish because of cultural
taboos. A health education message that does not recognize this fact will most likely be
ignored by the mothers. However, knowledge of this taboo will facilitate the
development of the appropriate messages that could modify this practice positively and
lead to increased provision of these foods to children.

DOCTOR’S LEADERSHIP ROLE IN HEALTH EDUCATION:

The doctor should play a leadership role in promoting community health development.
To play this role the doctor needs to develop skills in identifying the health needs and
resources of the community. This will assist in the development of educational
messages and strategies to respond to the community needs. He should be able to plan
and organize health education programmes that respond to the priority health needs in
his community. The doctor fulfils this leadership role through encouraging community
involvement, intersectoral collaboration and providing health education. He thus has a
responsibility for educating himself, other health workers and his patients on matters
relating to health development in his or her community.

COMMUNICATION SKILLS

Communication is the process of transferring messages and skills from the sender to
the receiver and from the receiver back to the sender. The receiver may be a person or
a group. If there is no response there is no communication.

Conditions which favour effective communications are:

a clear and concise message;
a message which is relevant to the needs and concerns of the receiver;
a message related to the experience and knowledge of the receiver.
Conducive environment (privacy, quietness)

It is the responsibility of the doctor or any other health educator to ensure that these
conditions are satisfied.

The receiver is ready to learn when:

he or she is interested in what is being said;
she or she is alert;
he or she is not occupied with some other urgent and worrying matter of a different kind;
the message is relevant to the recipient’s current condition or need.





260

Communication skills that are important to the health worker include:

ability to concentrate attention on the client and establish an active communication
process;
effective speaking;
explaining things to others;
persuading others;
Active listening;
asking relevant questions.

EFFECTIVE HEALTH EDUCATION METHODS

An effective educator should have clear concepts of educational objectives and a clear
statement of what the learner should be able to think, feel and do (behaviour,
observable activity) at the end of the learning period. The objectives are obtained from
the various tasks for solving the community health problems. Learning is the process
that results in relatively permanent change in behavior of the individual learner.
Learning is: controlled by the learner, affected by the total state of the learner, unique,
individual and the result of experience or repetition. The durability of cognitive and
behavioural change is proportional to the degree of active rather than passive
participation of the learner. Note the Chinese proverb “What I hear, I forget; what I see,
I recall; and what I do, I know”.

Use of Print Visual Aids:

Effective use of relevant visual aids may depict:
a severely dehydrated child and a well hydrated one;
a malnourished and a healthy one;
a child demonstrating difficulty in breathing and one showing normal breathing;
a pregnant adolescent in a school uniform and a happy adult mother.

Audio Visual Messages:

These may be presented in health facilities, through public radio, television and cinema.
This is a powerful method of health education as it combines entertainment and
education.

Lecture

Lecture is an easy way of providing a lot of information within a short period of time. It is
however not an efficient method in causing retention of the information. To accentuate
retention, a lecture must be interesting and to the point. It must be short as the attention
span of people wanes after about 30 minutes. The person delivering a lecture must
prepare and give real life examples or experiences. Allow time for discussion at the end.
The lecture should include the following:





261

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



262
counselor, the counselor is absent in the impersonal methods. The personal method
comprises counselling of an individual patient; and includes giving health education to a
small group. To be effective both the personal methods require establishment of
confidence and trust between the health worker and the individual or the group.

Counselling an Individual

Counselling an individual is the process of helping him to think clearly about his
problems, discover their causes and thus develop understanding of the causes. In the
process the counsellor:

first establishes a warm relationship with the client;
encourages the client to talk sincerely and trustingly about his or her problems;
assists the client in finding out the possible solutions;
helps select the best solution and
assists him on deciding the best action to take and to solve the problem himself.

This form of counselling is called non-directive. The decision arrived at is that of the
individual and not the counsellor.

Example: Providing feedback to the mother and praising her when she has learnt
something and when her baby is growing well improves learning. If the baby is not
growing, she is advised accordingly and sympathetically helped to reach a decision as
to what she can do to help the child acquire normal growth. Successful counselling
depends on the counsellor’s ability to establish a good rapport with the person being
counselled.

Group Counselling:
This is a method of helping a group of 10-15 people through discussing among
themselves to discover or define their health problems, to discover the most effective
solutions and to take action. In the discussion, the group members do offer each other
support for the appropriate behavior. The discussion is usually enjoyable with exchange
of experiences, enrichment of the individuals with ideas, and participation in decision-
making with other people.
The health worker first establishes rapport with creation of a relaxed friendly
atmosphere. He then introduces the discussion with a question, a film, a newspaper
cutting, a tape, a role play or a multiple choice question relevant to the issue. He also
summarizes from time to time and thinks of new directions the discussion should take.
During the discussion people are enabled to show their different values and attitudes, to
clarify their ideas and to make plans for a new course of action with the support of the
group. In this way, people can realize the motives behind their action. Some members
of the group may have already solved their problems and this would be helpful to those
still with a problem.








263

Impersonal Health Education Methods:

Impersonal health education methods include leaflets, posters, pamphlets, newspapers,
magazines, books, radio, television and songs. For spreading messages, the
impersonal methods have great penetrative power.

These impersonal methods have the following advantages:

reaching a large number of people;
repetition of the message;
serving as a reminder and reinforcement;
assuming more authority than personal contact.
The disadvantages of the impersonal methods are:
lack of opportunity for questions or discussion;
difficulties experienced by individuals in relating the message to their circumstances;
risk of being misunderstood.

NB: Combination of personal and impersonal health education methods occurs when
the mass media messages reinforce individual counselling, when individual counselling
clarifies the mass media messages and when small group discussions use radio
messages, television programmes and newspapers as the focus or starter.

IDENTIFYING THE HEALTH EDUCATION NEEDS
To provide effective training of the health workers and effective health education, the
doctor and other health workers should determine the learning needs of the individual
patients, health workers and the community.

The learning needs of individual patients are assessed by encouraging people to talk
about themselves, what interests them and what they do not understand. The educators
listen carefully and observe the gestures as well as facial expressions. During the
interview the participants may raise some questions and express some doubts,
anxieties or satisfactions. These are optimum opportunities of offering health education
and should not be missed. Other opportunities for providing health education of an
individual patient are immediately after recovery from an illness or at discharge from a
health facility.
The health education needs of a community may be discovered from health service
information and by community diagnosis through: carrying out knowledge, attitude and
practice surveys, focus group discussions and behavioural observations.
HEALTH EDUCATION IN SCHOOLS
A very important component of the community is schools. Through health education,
teachers and school children can serve as agents of cultural change by changing the
content of instruction in line with changing knowledge, social needs and values. Health
education in school has the major goal of promoting health as a value and is a valuable
means of promoting healthy behaviour for generations. In schools, health education is
largely given formally in classes. Informal health education in schools may be given
during the contacts of the students and the health workers. The contacts represent
some teachable moments to be exploited.



264

SELF EVALUATION QUESTIONS
How can you evaluate the achievements of a health education programme on control of
diarrhoeal diseases?
Explain what counselling is and list six qualities of a good counsellor.
Describe the reasons why some individuals do not immediately accept health education
messages.
Explain the role of informal leaders in health education.


REFERENCES

Guidelines for implementation of health education activities in Tanzania. Ministry of
Health, Tanzania. November, 1994.

Primary Health Care in Tanzania: An overview. A manual for Tanzanian Community
Health Educators. Ministry of Health, Tanzania, 1994.

Health Education, A manual for Tanzanian Community Health Educator, Ministry of
Health, Tanzania, 1994.

Determinants of Health, Introduction to A Manual for Tanzania Community Health
Educators, Ministry of Health Tanzania, 1994.

P Stanfield, N Bwibo Child health: A manual for medical and health workers in health
centres and rural hospitals. AMREF Rural Health Series 2005









265
CHAPTER 22

Integrated Management of Childhood illness*

Kopano Mukelabai

Introduction
Globally the number of child deaths
under five years of age has decreased by
almost one quarter between 1990 and
2006. In 2006 an estimated 9.6 million
children died before reaching their 5
th

birthday, as compared to 13 million
deaths in 1990. The reduction in under-
five child morality has varied widely
throughout the world. Children in low to
middle

Figures 1



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




February 2008
Child and Adolescent
Health and Development
CAH
Why are children dying?
cause-speci f ic mor t ali t y and cont r ibut i on of under nut r it ion
Diarrhoea
27%
Measles
6%
HIV/AIDS
5%
Other non-
communicable
7%
Injuries
5%
Pneumonia
30%
Other infectious
7%
Malaria
13%
Under
Study
Under
Study
%
Deat hs among children aged 28
days t o f ive years
(~ 6.6 million/ year )
Percent of deaths from this infection that
are due to the presence of undernutrition
Neonat al deat hs
(~ 4 million/ year )
Preterm
27%
Congenital
8%
Asphyxia
23%
Other
7%
Diarrhoea
3%
Tetanus
7%
Pneumonia/
sepsis 25%
% of deaths due to maternal and neonatal
undernutrition is under study
61%
45%
52%
57%
*Material in this chapter on IMCI is
mostly obtained from WHO and UNICEF
documents.







266
Since the year 2000, the global
community has been focused on
achieving the Millennium Development
Goals (MDGs). The MDG number 4 aims
at reducing under-five child mortality in
the world by two thirds between 1990
and 2015. Neonatal mortality currently
accounts for almost 40% of all children
dying under five years of age. This
number is estimated to be 4 million
neonatal deaths according to the
UNICEF 2008 State of the World’s
Children.

Between 1980 and 2000 child death in
the first month of life declined by a
quarter, while deaths between one month
and five years of age declined by a third.
Affordable and cost effective strategies
are now available in most countries to
prevent child deaths. These include
routine childhood immunization, oral
rehydration therapy, effective use of
antibiotics, regular use of insecticide
treated nets to prevent malaria, use of
newer anti-malaria drugs, breastfeeding
and prevention of mother to child
transmission of HIV and AIDS.

The IMCI strategy was developed by
WHO and UNICEF in collaboration with
many agencies and institutions, and has
now been adopted by many countries
and communities. The main objective of
the strategy is to reduce child deaths and
the frequency and severity of a child
illness and disability, hence contributing
to improved child growth and
development. The IMCI strategy
advocates for both preventive and
curative care and deals with aspects of
child nutrition, immunization, disease
prevention and health promotion. The
IMCI guidelines have been adapted at
country level to address the major
causes of child deaths and to provide
health information to health workers,
community health workers and to
families.

Objectives:
At the end of this chapter a student will
be able to: - Define the IMCI strategy
- Familiarize him/herself with IMCI
adapted guidelines in his/her
country
- Identify the major causes of under
five child mortality in his/her
country.
- Be conversant with the national
strategy to achieve the MDGs
number 4
- Assess a sick child, including
his/her immunization and
nutritional status
- Classify the child’s illness, note
the danger signs, and decide if the
child needs urgent medical
referral.
- Give essential pre-referral
treatment (e.g., antibiotic, anti-
malarial, anti pyretic, or anti-
convulsant etc.)
- Teach the mother how to
administer treatment at home for
example an antibiotic, anti-
malarial etc.
- Advise the mother on proper
feeding practices and when to
return to the health centres if the
child becomes more sick.
- Do a follow up assessment and
give treatment for children coming
for follow-up.



267
Infant and childhood mortality are
sensitive indicators of inequity and
poverty. It is no surprise to find that the
children who are
most commonly and
severely ill, are
often those who are
malnourished, and
those who are most
vulnerable. They
often belong to
underprivileged
populations of low income countries.
However, even within middle-income and
so called industrialized countries, there
are often poor and neglected
communities; these are often neglected
geographical areas where childhood
mortality remains high. Millions of
children in these areas are often caught
in the vicious cycle of poverty and ill
health - poverty leads to ill health and ill
health breeds poverty.

Quality of care is another important
indicator of inequalities in child health.
Every day, millions of parents seek
health care for their children, taking them
to hospitals, health centers, pharmacies,
doctors, and traditional healers. Surveys
reveal that many sick children are not
properly assessed and treated by these
health providers, and that their parents
are poorly advised. ³ At first-level health
facilities in low-income countries,
diagnostic supports such as radiology
and laboratory services are minimal or
non-existent, and drugs and equipment,
combined with an irregular flow of
patients, leave doctors at this level with
few opportunities to practice complicated
clinical procedures. Instead, they often
rely on history and signs and symptoms
to determine a course of management
that makes the best use of available
resources.

Providing quality care to sick children in
these conditions is a serious challenge.
Yet how can this situation be reversed?
Experience and scientific evidence show
that improvements in child health are not
necessarily dependant on the use of
sophisticated and expensive
technologies, but rather on effective
strategies that are based on a holistic
approach, are available to the majority of
those in need, and which take into count
the capacity and structure of health
systems, as well as traditions and beliefs
in the community.

Rationale for an evidence based
syndromic approach to case
management

Many well-known prevention and
treatment strategies have already proven
effective for saving young lives.
Childhood vaccinations have
successfully reduced
deaths due to
measles. Oral
rehydration therapy
has contributed to a
major reduction in
diarrhoeal deaths.
Effective antibiotics
have saved millions of
children with
pneumonia. Prompt
treatment of malaria
has allowed more
children to recover
and lead healthy lives.
Even modest
improvements in breastfeeding practice
have reduced childhood deaths.

While each of these interventions has
shown great success, accumulating
evidence approach to managing sick
children is needed to achieve better
outcomes. Child health programmes
need to move beyond single disease to
addressing the overall health and well-
being of the child. Because many
children present with over lapping signs
and symptoms of disease, a single
diagnosis can be difficult, and may not be
Improvements
in child health are
not necessarily
dependent on the use
of sophisticated and
expensive
technologies.

A more integrated
approach to
managing sick
children is needed
to achieve better
outcomes.
Child health
programmes need
to move beyond
addressing single
disease to
addressing the
overall health and
well-being of the
child.




268
feasible or appropriate. This is especially
true for first-level health facilities where
examinations involve few instruments,
little or no laboratory tests, and no
instruments, little or laboratory tests, and
no X-ray.

During the mid-1990s, the World Health
Organization (WHO), in collaboration
with UNICEF and many other agencies,
institutions and individuals, responded to
this challenge by developing a strategy
known as the Integrated Management of
Childhood Illness (IMCI). Although the
major reason for developing the ICMI
strategy stemmed from the needs of
curative care, the strategy also
addresses aspects of nutrition,
immunization, and other important
elements of disease prevention and
health promotion. The objectives of the
strategy are to reduce death and the
frequency and severity of illness and
disability, and to
contribute to
improved growth
and development.

The ICMI clinical
guidelines target
children less than 5
years old - the age
group that bears
the highest burden
of deaths from common childhood
diseases. (Figure 1).

The guidelines take an evidence-based,
syndromic approach to case
management that supports the rational,
effective and affordable use of drugs and
diagnostic tools. Evidence-based
medicine stresses the importance of
evaluation of evidence from clinical
research and cautions against use of
intuitions, unsystematic clinical
experience, and untested
pathophysiologic reasoning for medical
decision-making. In situations where
laboratory supports and clinical
resources are limited, the syndromic
approach is a more realistic and cost-
effective way to manage patients. Careful
and systematic assessment of common
symptoms and well-selected clinical
signs provides sufficient information to
guide rational and effective actions.

An evidence-based syndromic approach
can be used to determine the:
 Health problem (s) the child may
have
 Severity of the child’s condition;
 Actions that can be taken care for
that child (e.g. refer the child
immediately, manage with
available resources, or manage at
home).


Fig. 2
In addition, ICMI promotes:

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

Careful and
systematic
assessment of
common symptoms
and well-selected
specific clinical signs
provide sufficient
information to guide
rational and
effective actions.




269
February 2008
Child and Adolescent
Health and Development
CAH
Main components of IMCI
Knowledge,
belief s
and skills of
caret akers
I mprove
healt h worker
perf ormance
St r engt hen
healt h syst em
support s

home, before the child has any contract
with a health facility.

Components of the integrated
approach

The ICMI strategy includes both
preventive and curative interventions that
aim to improve practices in health
facilities, the health system and at home.
At the core of the strategy is integrated
case management of the most common
childhood problems with a focus on the
most common causes of death.




The strategy includes three main
components:

 Improvements in the case-
management skills of health staff
through the provision of locally
adapted guidelines on integrated
management of childhood illness
and activities to promote their use;
 Improvements in the overall
system required for effective
management of childhood illness;
 Improvements in family and
community health care practices.
See Fig. 2.

The Principle of integrated care
The ICMI guidelines are based on the
following principles:
 All sick children must be examined
for
“general danger signs” which
indicate the need for immediate
referral or admission to a hospital.

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

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

These signs were selected considering
the conditions and realities of first-level
health facilities.
 A combination of individual signs
leads to a child’s classification (s)
rather than a diagnosis.
Classification (s) indicates the
severity of condition (s). They call for
specific actions based on whether the
child (a) Should be urgently
referred to another level of care,
(b) requires specific treatments
(such as antibiotics or ant malaria
treatment), or (c) may be safely
managed at home.
 The classification are colour
coded:



270
“pink” suggests hospital referral or
admission, “yellow” indicates
initiation of treatment, “green”
indicates calls for home treatment.

The ICMI guidelines address most, but
not all, of the major reasons a sick
child is brought to a clinic.
A child returning with chronic
problems or less common illness may
require special care. The guidelines
do not describe the management
of trauma or other acute emergencies
due to accidents or injuries.

 IMCI management procedures use a
limited number of essential
drugs and encourage active
participation of caretakers in the
treatment of children.
 An essential component of the IMCI
guidelines is the counselling of
caretaker about home management,
including counselling about feeding,
fluids and when
to return to a health facility.

Adapting the guidelines to a country’s
situation

The underlying principles of the IMCI
guidelines are constant. However, in
each country the IMCI clinical guidelines
should be adapted to;

 Cover the most serious childhood
illness typically seen at first-level
health facilities;

 Make the guidelines congruent with
national treatment guidelines and
other policies; and


 Make the IMCI implementation
feasible
through the health system and by
families caring for their children at
home.

Adaption of the ICMI guidelines normally
is co-ordinated by national health
regulating body (e.g.
Ministry of Health) and incorporates
decisions carefully made by national
health experts.
For this reason, some clinical signs and
details of clinical procedures described
below may differ from those used in a
particular country. The principles used for
management of sick children, however,
are fully applicable in all situations.

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

Outpatient health facility
 Assessment
 Classification treatment or counselling
of the
child’s caretaker (|depending on the
classification(s) Identified);
 Follow-up care

Referral health facility
 Emergency triage assessment
and treatment (ETAT)’



271
 Diagnosis, treatment and monitoring
of patient progress.

Appropriate home management
 Teaching the mother or other
caretaker to give oral drugs and treat
local infections at home;
 Counselling the mother or other
caretaker about food (feeding
recommendations, feeding problems,);
fluids; when to return to the health
facility; and her own health.
Depending on child’s age, various clinical
signs and symptoms have different
degrees of reliability and diagnostic value
and importance. Therefore, The IMCI
guidelines recommend case
management procedures based on two
age categories:
 Children age 2 months up to 5
years
 Young infants age 1 week up to 2
months





February 2008
Child and Adolescent
Health and Development
CAH
Key family practices (1)
For physical growth and mental development
1. Breastfeed infants exclusively for six months.
Mothers found to be HIV positive require counselling
about possible alternatives to breastfeeding
2. Starting at the end of six months of age, feed children
freshly prepared energy and nutrient rich complementary
foods, while continuing to breastfeed up to two years or
longer
3. Ensure that children receive adequate amounts of
micronutrients (vitamin A and iron, in particular), either in
their diet or through supplementation
4. Promote mental and social development by responding
to a child’s needs for care, and through talking, playing,
and providing a stimulating environment





272
February 2008
Child and Adolescent
Health and Development
CAH
Key family practices (2)
For disease prevention
• Dispose of faeces safely, including children’s; and wash
hands after defecation, before preparing meals, and
before feeding children
• Take children as scheduled to complete a full course of
immunizations (BCG, DPT, OPV, Hib, and measles) before
their first birthday
• Protect children in malaria-endemic areas, by ensuring
that they sleep under insecticide-treated bednets


February 2008
Child and Adolescent
Health and Development
CAH
Key family practices (3)
For appropriate home care
1. Continue to feed and offer more fluids, including
breastmilk, to children when they are sick
2. Give sick children appropriate home treatment for
infections
3. Follow the health worker’s advice about treatment, follow-
up and referral
For seeking care
1. Recognise when sick children need treatment outside the
home and seek care from appropriate providers
2. Ensure that every pregnant woman has adequate antenatal
care
















273

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





274
Outpatient management of children
Age 2 months up to 5 years

Assessment of sick children

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

History taking – communicating
with the caretaker

History taking
General danger signs
Main symptoms
Cough or difficult breathing
Diarrhoea
Fever
Ear problems
Nutritional status
Immunization status
Other problems

It is critical to communicate effectively
with the child’s mother or caretaker.
Good communication techniques and
an integrated assessment are
required to ensure that common
problems or signs of disease or
malnutrition are not overlooked. Using
good communication helps to
reassure the mother or caretaker that
the child will receive good care. In
addition, the success of home
treatment depends on how well the
mother or caretaker knows how to
give the treatment and understands
its importance.
The steps to good communication
are:
 Listen carefully to what the
caretaker says.
This will show her/him that you take their
concerns seriously.
 Use words the caretaker
understands Try to use local
words and avoid medical terminology.
 Give the caretaker time to answer
questions.
S/he may need time to reflect and
decide if a clinical sign is present.

 Ask additional questions when the
caretaker is not sure about the
answer. A caretaker may not be sure
if a symptom or
clinical sign is
present. Ask
additional questions
to help her/him give
clear answers.

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





INABILI TY TO DRI NK
OR BREAST FEED



DANGER
SIGNS



275
signs” that do not point to a particular
diagnosis. For example, a child who is
lethargic or unconscious may have
meningitis, severe pneumonia, cerebral
malaria or another severe disease. Great
care should be taken to ensure that
these general danger signs are not
overlooked because they suggest that a
child is severely ill and needs urgent
attention.
The following danger signs should be
routinely checked in all children.
 The child has had convulsions
during the
present illness. Convulsions may be
the result of fever. In this instance,
they do little harm beyond frightening
the mother. On the other hand,
convulsions may be associated with
meningitis, cerebral malaria or other
life-threatening conditions. All children
who have had convulsions during the
present illness should be considered
seriously ill.

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

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


The child vomits everything. The
vomiting
It may be a sign of serious illness, but it
is also important to note because such a
child will not be able to take medication
or fluids for rehydration.
If a child has one or more of these
signs, she/he must be considered
seriously ill and will almost always need
referral. In order to start treatment for
severe illnesses without delay, the child
should be quickly assessed for the most
important causes of serious illness and
death – acute respiratory infection (ARI),
diarrhoea, and fever (especially
associated with malaria and measles). A
rapid assessment of nutritional status is
also essential, as malnutrition is another
main cause of death.
Checking main symptoms
After checking for general danger signs,
the health care provider must check for
main symptoms. The generic IMCI
clinical guidelines suggest the following
four: (1) cough or difficult breathing; (2)
diarrhoea; (3) fever; and (4) ear problems
The first three symptoms are included
because they often result in death. Ear
problems are included because they are
considered one of the main causes of
childhood disability in low-and middle –
income countries.
Child presenting with cough or difficult
breathing should first be assessed for
general danger signs. This child may
have pneumonia or another severe
respiratory infection. After checking for
danger signs, it is essential to ask the
child’s caretaker about this main
symptom.



276
Clinical assessment
Three key clinical signs are used to
assess a sick child with cough or difficult
breathing:
 Respiratory rate, which distinguishes
children who have pneumonia from
those who do not;

 Lower chest wall indrawing, which
indicates severe pneumonia; and


 Stridor, which indicates those with
severe
pneumonia which requires hospital
admission.
No single clinical sign has a better
combination of sensitivity and specificity
to detect pneumonia in children under 5
than respiratory rate, specifically fast
breathing. Even auscultation by an
expert is less sensitive as a single sign.
Cut –off rates for fast breathing (the point
at which fast breathing is considered to
be fast) depend on the child’s age.
Normal breathing rates are higher in
children age 2 months up to 12 months
than in children age 12 months up to 5
years.
Child’s age Cut-off rate fast
breathing
2 months up to 12 months 50 breaths
per minute or
more
12 months up to 5 years 40 breaths
per minute or
more


Note: The specificity of respiratory rate
for detecting pneumonia among the
population. In areas with high levels of
viral pneumonia, respiratory rate has
relatively modest specificity.
Nevertheless, even if the use of
respiratory rate leads to some
overtreatment, this will still be small
compared with the current use of
antibiotics for all children with an ARI, as
occurs in many clinics.
Lower chest wall indrawing, defined as
the inward movement of the bony
structure of the chest wall with
inspiration, is a useful indicator of severe
pneumonia. It is more specific than
“intercostal indrawing,” which concerns
the soft tissue between the ribs without
involvement of the bony structure of the
chest wall.
8
Chest indrawing should only
be considered present if it is consistently
present in a calm child. Agitation, a
blocked nose or breastfeeding can all
cause temporary chest indrawing.
Stridor is a harsh noise made when the
child inhales (breathes in). Children who
have stridor when calm have a
substantial risk of obstruction and should
be referred. Some children with mild
croup have stridor only when crying or
agitated. This should not be the basis for
indiscriminate referral. Sometimes a
wheezing noise is heard when the child
exhales (breathes out). This is not
stridor. A Wheezing sound is most often
associated with asthma. Experience
suggests that even where asthma rates
are high, mortality from asthma is
relatively uncommon. In some cases,
especially when a child has wheezing
when exhaling, the final decision on
presence or absence of fast breathing
can be made after a test with a rapid
acting bronchodilator (if available). At this
level, no distinction is made between



277
children with bronchiolitis and those with
pneumonia.


Classification of cough or difficult
breathing
Based on a combination of the above
clinical signs, children presenting with
cough or difficult breathing can be
classified into three categories:
- Those who require referral for
possible severe pneumonia or very
severe disease.

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


- Any general
danger sign or
- Chest
indrawing
- Stridor in
calm child

SEVERE
PNEUMONIA
OR
VERY SEVERE
DISEASE


- Those who require antibiotics as
outpatient
because they are highly likely to have
bacterial pneumonia.

This group includes all children with
fast respiratory rate for age. Fast
breathing, as defined by WHO,
detects about 80 percent of children
with pneumonia who need antibiotic
treatment. Treatment based on this
classification has been shown to
reduce mortality.


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


- No signs of
pneumonia or very
severe disease
NO
PNEUMONIA:
COUGH OR
COLD
Diarrhoea
A child presenting with diarrhoea should
first be assessed for general danger
signs and the child’s caretaker should be
asked if the child has cough or difficult
breathing.
Diarrhoea is the nest symptom that
should be routinely checked in every
child brought to the clinic. A child with
diarrhoea may have three potentially
lethal conditions: (1) acute watery
diarrhoea (including cholera); (2)
dysentery (bloody diarrhoea); and (3)
persistent diarrhoea (diarrhoea that lasts
more than 14 days). All children with
diarrhoea; (a) signs of dehydration (b)

- Fast breathing




278
how long the child has had diarrhoea;
and (c) blood in the stool to determine if
the child has dysentery.
Clinical assessment
All children with diarrhoea should be
checked to determine the duration of
diarrhoea, if blood is present in the stool
and if dehydration is present. A number
of clinical signs are used to determine
the level of dehydration.
Child’s general condition. Depending
on the degree of dehydration, a child with
diarrhoea may be lethargic or
unconscious (this is also a general
danger sign) or look restless/irritable.
Only children who cannot be consoled
and calmed should be considered
restless or irritable.
Sunken eyes. The eyes of a dehydrated
child may look sunken. In a severely
malnourished child who is visibly wasted
(that is, who has marasmus), the eyes
may always look sunken, even if the child
is not dehydrated. Even though the sign
“sunken eyes” is less reliable in a visibly
wasted child, it can still be used to
classify the child’s dehydration.
Child’s reaction when offered to drink.
A child is not able to drink if s/he is not
able to take fluid in his/her mouth and
swallow it. For example, a child may not
be able to drink because s/he is lethargic
or unconscious. A child is drinking poorly
if the child is weak and cannot drink
without help. S/he may be able to
swallow only if fluid is put in his/her
mouth. A child has the sign drinking
eagerly, thirty if it is clear that the child
wants to drink. Notice if you offer him/her
water. When the water tank is taken
away, sees if the child takes a drink only
which encouragement and does not want
to drink more, s/he does not have the
sign “drinking eagerly, thirsty.”
Elasticity of skin. Check elasticity using
the skin pinch test. When released, the
sin pinch goes back either very slowly
longer than 2 seconds), or slowly (skin
stays up even for a brief instant), or
immediately. In a child with marasmus
(severe malnutrition), the skin may go
back slowly even if the child is not
dehydrated. In an overweight child, or a
child with oedema, the skin may go back
immediately even if the child is
dehydrated.







After the child is assessed for
dehydration, the caretaker of child with
diarrhoea should be asked how long the
child has had diarrhoea and if there is
blood in the stool. This will allow
identification of children with persistent
diarrhoea and dysentery.

Classification of dehydration

Based on combination of the above
clinical signs, children presenting with
diarrhoea are classified into three
categories:
- Those who have severe dehydration
and who require immediate IV
infusion, nasogastric or oral fluid
replacement according to the
Standard procedures for skin pinch test
 Locate the area on the child’s abdomen
halfway between the umbilicus and the
side of the abdomen; then pinch the skin
using the thumb and first finger.

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


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



279
WHO treatment guidelines described
in Plan C (see figure 4 under
treatment procedures).

Patients have severe dehydration if
they have a fluid deficit equalling
greater than 10 percent of their body
weight. A child is severely dehydrated
if he/she has any combination of two
of the following signs: is lethargic or
unconscious, is not able to drink or is
drinking poorly, has sunken skin, or a
skin pinch goes back very slowly.


Two of the following
signs:

- Restless,
irritable
- Sunken eye
- Drinks
eagerly, thirsty
- Skin pinch
goes back slowly


SEVERE
DEHYDRATION
- Those who have some dehydration
and who
require active oral treatment with ORS
solution
according to Who treatment guidelines
described
in pan B (see Figure 5 under treatment

procedures).
Children who have any combination of
the following two signs are included in
this group: restless/irritable, sunken
eyes, drinks eagerly/thirsty. Skin pinch
goes back slowly.
Children with some dehydration have a
fluid deficit equaling 5 to 10 percent of
their body weight. This classification
includes both “mild” and “moderate”
dehydration, which is a descriptive term
used in most paediatric textbooks.


Two of the following
signs:

- Restless,
irritable
- Sunken eye
- Drinks eagerly,
thirsty
- Skin pinch
goes back slowly


SOME
DEHYDRATI
ON

- Those children with diarrhoea who
have no
dehydration.
Patients with diarrhoea but no signs
of dehydration usually have a fluid
deficit, but equal to less than 5
percent of their body weight. Although
these children lack distinct signs of
dehydration, they should be given
more fluids than usual to prevent
dehydration from developing as
specified in Who Treatment Plan A
(see figure 5 under treatment
procedures).


Not enough
signs to classify
as some or
severe
dehydration

NO
DEHYDRATION
Note: Antibiotics should not be used
routinely for treatment of diarrhoea.
Most diarrhoea episodes are caused
by agents for whom antimicrobials are
not effective, e.g., viruses, or by
bacteria that must first be cultured to
determine their sensitivity to
antimicrobials. A culture, however, is



280
costly and requires several days to
receive the test results. Moreover,
most laboratories are unable to detect
many of the important bacterial
causes of diarrhoea.
Note: Anti-diarrhoea drugs - including
anti-motility agents (e.g., loperamide,
diphenoxylate, codeine, tincture of
opium), adsorbents (e.g., Kaolin,
attapulgite, smectite), live bacterial
cultures (e.g., lactobacillus,
Streptococcus faecium), and charcoal
– do not provide practical benefits for
children with acute diarrhoea, and
some may have dangerous side
effects. The drugs should never be
given to children less than 5 years
old.
Classification of persistent diarrhoea
Persistent diarrhoea is an episode of
diarrhoea, with or without blood, which
begins acutely and lasts at least 14
days. It accounts for up to 15 percent of
all episodes of diarrhoea but is
associated with 30 to 50 percent of
deaths. Persistent diarrhoea is usually
associated with weight loss and often
with serious non-intestinal infections.
Many children who develop persistent
diarrhoea are malnourished, greatly
increasing the risk of death. Persistent
diarrhoea almost never occurs in infants
who are exclusively breast-fed.

All children with diarrhoea for 14 days or
more should be classified based on the
presence or absence of any
dehydration.
- Children with severe persistent
diarrhoea who also have any degree
of dehydration
require special
treatment and
should not be
managed at the
outpatient health
facility.

Referral to a
hospital is required. As a rule,
treatment of dehydration should be
initiated first, unless there is another
severe classification.


- Dehydration
Present

SEVERE
PERSISITENT
DIARRHOEA

- Children with severe persistent
diarrhoea and no signs of dehydration
can be safely managed in the
out-patient clinic, at least initially.
Proper feeding is the most important
aspect of treatment for most children
with persistent diarrhoea. The goals of
nutritional therapy are to: (a)
temporarily reduce the amount of
animal milk (or Lactose) In the diet; (b)
provide a sufficient intake of energy,
protein, vitamins and minerals to
facilitate the repair process in the
damaged gut mucus and improve
nutritional status; (c) avoiding giving
foods or drinks that may aggravate the
diarrhoea; and (d) ensure adequate
food intake during convalescence to
correct any malnutrition.
Persistent
diarrhoea
accounts for up to
15 percent of all
episodes of
diarrhoea but is
associated with 30
to 50 percent of
deaths



281
Routine treatment of persistent
diarrhoea with antimicrobials is not
effective. Some children, however,
have non-intestinal (or intestinal)
infections that require specific
antimicrobial therapy. The persistent
diarrhoea of such children will not
improve until these infections are
diagnosed and treated correctly.

- No
dehydration
PERSISTENT
DIARRHOEA



Classification of dysentery

The mother or care taker of a child with
diarrhoea should be asked if there is
blood in the stool.

 A child is classified as having
dysentery if the mother or
caretaker reports blood in the child’s
stool.


- B
lood
in the
stool

DYSE
NTRY
It is necessary to
examine the stool
or perform laboratory tests diagnose
dysentery. Stool culture, to detect
pathogenic bacteria, is rarely possible.
Moreover, at least two days are required
to obtain the results of a culture.
Although :dysentery” is often described
as a syndrome of bloody diarrhoea with
fever, abdominal cramps, rectal pain and
mucoid stools, these features do not
always accompany bloody diarrhoea, nor
do they necessarily define
its etiology or determine appropriate
treatment.

Bloody diarrhoea in young children is
usually a
sign of invasive enteric infection that
carries a substantial risk of serious
morbidity and death. About 10 percent
of all diarrhoea episodes in children
under 5 years old are dysenteric, but
these cause up to 15 percent of all
diarrhoeal deaths. ¹¹

Dysentery is especially severe in infants
and in children who are under
nourished, who develop clinically-
evident dehydration during their illness,
or who are not breast –fed. It also has a
more harmful effect on nutritional status
than acute watery diarrhoea. Dysentery
occurs with increased frequency and
severity in children who have measles
or have had measles in the preceding
month, and diarrhoeal episodes which
begin with dysentery are more likely to
become persistent than those that start
without blood in the stool.


All children with dysentery (bloody
diarrhoea) should be treated promptly
with an antibiotic effective against
Shigella because : (a) bloody diarrhoea
in children under 5 is caused much
more frequently by shigella than by any
other pathogen; (b) shigellosis is more
likely than other causes of diarrhoea to
result in complications and death if
effective antimicrobial therapy is not
begun promptly; and (c ) early treatment
of shigellosis with an effective antibiotic
About 10 percent of
all diarrhoea
episodes in children
under 5 years old are
dysenteric, but these
cause up to 15
percent of all
diarrhoea deaths.



282
substantially reduces the risk of severe
morbidity or death.

Fever
All sick children should be checked for
fever. Fever is a very common condition
and is often the main reason for bringing
children to the health centers. It may be
caused by minor infections, but may also
be the most obvious sign of a life-
threatening illness, particularly malaria
(especially lethal malaria P.Falciparum),
or other severe infections, including
meningitis, typhoid fever, or measles.
When diagnostic capacity is limited, it is
important first to identify those children
who need urgent referral with appropriate
pre-referral treatment (anti-malaria or
antibacterial).

Clinical assessment

Body temperature should be checked in
all sick children brought to an outpatient
clinic. Children are considered to have
fever if their body temperature is above
37.5ºC axillary (38ºC rectal). In the
absence of a thermometer, children are
considered to have fever if they feel hot.
Fever also may be recognized based on
a history of fever.

A child presenting with fever should be
assessed for:
Stiff neck. A stiff neck may be a sign of
meningitis, cerebral malaria or another
very severe febrile disease. If the child
is conscious and alert, check stuffiness
by tickling the feet, asking the child to
bend his/her neck to look down or by
very gently bending the child’s head
forward. It should move freely.

Risk of malaria and other endemic
infections.
In situations where routine microscopy is
not available or the results may be
delayed, the risk of malaria transmission
must be defined. The World Health
Organization (WHO) has proposed
definitions of malaria risk settings for
countries and areas with risk of malaria
caused by P.falciparum. A high malaria
risk setting is defined as a situation in
which more than 5 percent of cases of
febrile disease in children age 2 to 59
months are malarial disease. A low
malarial risk setting is a situation where
fewer than 5 percent of cases of febrile
disease in children age 2 to 59 months
are malarial disease, but in which the risk
is not negligible. If malaria transmission
does not normally occur in area, and
imported malaria is uncommon, the
setting is considered to have no malaria
risk. Malaria risk can vary by season.
The national malaria control programme
normally defines areas of malaria risk in
a country.

If other endemic infections with public
health importance for children under 5
are present in the area (e.g., dengue
hemorrhagic fever or relapsing fever),
their risk should also be considered. In
such situations, the national health
authorities normally adapt the IMCI
clinical guidelines locally.

Runny nose. When malaria risk is low, a
child with fever and a runny nose does
not need an anti malarial. This child’s
fever is probably due to a common cold.

Duration of fever. Most fevers due to
viral illnesses go away within a few days.
A fever that has been present every day
for more than five days can mean that
the child has a more severe disease



283
such as typhoid fever. If the fever has
been present for more than five days, it is
important to check whether the fever has
been present every day.

Measles. Considering the high risk of
complications including death due to
measles, children with fever should be
assessed for signs of current or previous
measles (within the last three months).
Measles deaths occur from pneumonia
and laryningotracheitis (67 percent),
diarrhoea (25 percent), measles alone,
and a few from encephalitis. Other
complications ( usually nonfatal) include
conjunctivitis, otitis media, and mouth
ulcers. Significant disability can result
from measles including blindness, severe
malnutrition, chronic lung disease
(bronchiectasis and recurrent infection),
and neurologic dysfunction.
12

Detection of acute (current) measles is
based on fever with a generalized rash,
plus at least one of the following signs:
red eyes, runny nose, or cough. The
mother should be asked about the
occurrence of measles within the last
three months (recent measles). Despite
great success in improving immunization
coverage in many countries, substantial
numbers of measles cases and deaths
continue to occur. Although the vaccine
should be given at 9 months of age,
immunization often does not take place
(because of false contraindications, lake
of vaccine, or failure of the cold chain
system), or is delayed.

In addition, many measles cases occur
early in a child’s life (between 6 and 8
months of age), especially in urban and
refugee populations.

If the child has measles currently or
within the last three months, s/he should
be assessed for possible complications.
Measles damages the epithelial surfaces
and immune system, and lowers vitamin
A levels. This results in increased
susceptibility to infections caused by
pneumococcus, gram-negative bacteria,
and adenovirus. Recrudescence of
herpes virus, Candida, and malaria can
also occur during measles infection. It is
important to check every child with recent
or current measles for possible
complications such as pneumonia, stridor
in a calm child, diarrhoea, malnutrition
and ear infection are assessed in
relevant sections of the IMCI clinical
guidelines.
Before classifying fever, check for
obvious causes of fever (e.g. ear pain,
burn, abscess, etc.).

Classification of fever

 All children with fever and any
general danger sign or stiff neck are
classified as having very severe
febrile disease and should be urgently
referred to a hospital after pre-referral
treatment with antibiotics (the same
choice as for severe pneumonia or very
severe disease).

Note: In areas where malaria
P.falciparum is present, such children
should also receive a pre-referral dose of
an antimalarial (intramuscular quinine).


- Any danger sign
or
- Stiff neck

VERY SEVERE
FEBRILE
DISEASE



284
Further classifications will depend on
the level of malaria risk in the area.

 In a high malaria risk area or
season, children with fever and no
general danger sign or stiff neck should
be classified as having Malaria

Presumptive treatment for malaria should
be given to all children who present with
fever in the clinic, or who have a history
of fever during this illness. Although a
substantial number of children will be
treated for malaria when in fact they have
another febrile illness, presumptive
treatment for malaria is justified in this
category given the high rate of malaria
risk and the possibility that another
illness might cause the malaria infection
to progress. This recommendation is
intended to maximize sensitivity,
ensuring that as many true cases as
possible receive proper ant malarial
treatment.
13

-
Fever (by
history or feels
hot or
temperature

37.5
O
C

or above)


MALARIA
- In a low malaria risk area or season,
children with fever (or history of fever)
and no general danger sign or stiff neck
are classified as having Malaria and
given an ant malarial only if they have
no runny nose (a sign of ARI), no
measles, and no other obvious cause of
fever (pneumonia, sore throat, etc.).
Evidence of another infection lowers the
probability that the child’s illness is due to
malaria. Therefore, children in a low
malaria risk area or season, who have
evidence of another infection, should not
be given an antimalarial.


- No runny
nose and
No measles
and
No other
causes of
fever

MALARIA
- In a low malaria risk area or season,
children with runny nose, measles or
clinical signs of other possible
causes of fever are classified as having
fever – malaria unlikely. These
children need follow-up. If their
fever lasts more than five days, they
should be referred for further
assessment to determine causes of
prolonged pyrexia. If possible, in low
malaria risk settings, a simple malaria
laboratory test is highly advisable.


- Runny nose
PRESENT OR
- Measles
PRESENT or
- Other causes
of fever
PRESENT



FEVER –
MALARIA
UNLIKELY

- In a no malaria risk area or season,
An attempt should be
made to distinguish cases of
possible bacterial infection,
which require antibiotic
treatment, from cases of non-



285
complicated viral I
infection. Presence of a
runny nose in such situations
has no or very little diagnostic
value.

When there are obvious causes of fever
present such as pneumonia, ear
infection, or sore throat, children could
be classified as having possible
bacterial infection and treated
accordingly.



- Obvious causes
of fever
POSSIBLE
BACTERIAL
INFECTION
 In a no malaria risk area or season, if
no clinical signs of obvious infection are
found, the working classification
becomes uncomplicated fever.

Such children should be followed up in
two days and assessed further. As in
other situations, all children with fever
lasting more than five days should be
referred for further assessment.


- NO obvious
causes
of fever


UNCOMPLICATED
FEVER
Note: Children with high fever, defined as
an axillary temperature greater than
39.5
o
C or a rectal greater than 39
o
C,
should be given a single dose of
paracetamol to combat hyperthermia.

Classification of measles
All children with fever should be checked
for signs of current or recent measles
(within the last three months) and
measles complications.

 Severe complicated measles is
present when a child with measles
displays any general danger sign, or
has severe stomatitis with deep and
extensive mouth ulcers or severe eye
complications, such as clouding of
the cornea. These children should be
urgently referred to a hospital.

- Any danger
sign; or
- Clouding of
cornea or
- Deep or
extensive
mouth ulcers

SEVERE
COMPLICATED
MEASLES
 Children with severe measles
complications, such as pus draining
from the eye (a sign of conjunctivitis)
or non –deep and non –extensive
mouth ulcers, are classified as
measles with eye or mouth
complications. These children can be
safely treated at the outpatient facility.
This treatment includes oral vitamin A,
tetracycline ointment for children with
pus draining from the eye, and gentian
violet for children with mouth ulcers.
Children classified with pneumonia,
diarrhoea or ear infection AND measles
with eye or mouth complications should
be treated for the other classification (s)
AND given a vitamin A treatment
regimen. Because measles depresses
the immune system, these children may



286
also be referred to hospital for
treatment.


- Pus
draining
from the
eye or
- Mouth
ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS

 If no signs of measles complications
have been found after a complete
examination, a child is classified as
having Measles. These children can
be effectively and safely managed at
home with vitamin A treatment.


- Measles now or
within
the last three
months
MEASLES
Ear problems are the next condition that
should be checked in all children brought
to the outpatient health facility. A child
presenting with an ear problem should
first be assessed for general danger
signs, cough or difficult breathing,
diarrhea and fever. A child with an ear
problem may have an ear infection.
Although ear infections rarely cause
death, they are the main cause of
deafness in low-income areas, which in
turn leads to learning problems.

Clinical assessment
When otoscopy is not available, look for
the following simple clinical signs:

Tender swelling behind the ear. The
most serious complication of an ear
infection is a deep infection in the
mastoid bone. It usually manifests with
tender swelling behind one of the child’s
ears. In infants, this tender swelling also
may be above the ear. When both
tenderness and swelling are present, the
sign is considered positive and should
not be mistaken for swollen lymph nodes.
Ear pain. In the early stages of acute
otitis media, a child may have ear pain,
which usually causes the child to become
irritable and rub the ear frequently.
Ear discharge or pus. This is another
important sign of an ear infection. When
a mother reports an ear discharge, the
health care provider should check for
pus drainage from the ears and find out
how long the discharge has been
present.
Classification of ear problems
Based on the simple clinical signs above,
the child’s condition can be classified in
the following ways:
 Children presenting with tenderness
and swelling of the mastoid bone are
classified as having mastoiditis and
should be referred to the hospital for
treatment. Before referral, these
children first should receive a dose of
antibiotic and a single dose of
paracetamol for pain.


- Tender
welling
behind the
ear

MASTOIDITIS



287
 Children with ear pain or ear
discharge (or pus) for fewer than 14
days are classified as having acute
ear infection \and should be treated
for five days with the same first-line
antibiotic as for pneumonia.



- Ear discharge for
fewer than 14 days
or

- Ear pain

ACUTE EAR
INFECTION

 If there is ear discharge (or pus) for
more than 14 days, the child’s
classification is chronic ear
infection. Dry the ear by wicking.
Generally, antibiotics are not
recommended because they are
expensive and their efficacy is not
proven.


- Ear discharge
for more than 14
days

CHRONIC EAR
INFECTION
 If no signs of ear infection are found,
children are classified as having no
ear infection and do not require any
specific treatment.


- No ear pain and
No ear discharge
seen draining from the
ear


NO EAR
INFECTION
Checking nutritional status-
malnutrition and anaemia

After assessing for general danger signs
and the four main symptoms, all
children should be assessed for
malnutrition and anaemia. There are two
main reasons for routine assessment of
nutritional status in sick children: (1) to
identify children with severe malnutrition
who are at increased risk of mortality
and need urgent referral to provide
active treatment; and (2) to identify
children with sub-optimal growth
resulting from ongoing deficits in dietary
intake plus repeated episodes of
infection (stunting), and who may benefit
from nutritional counselling and
resolution of feeding problems. All
children also should be assessed for
anaemia.


Clinical assessment
Because reliable height boards are
difficult to find in most outpatient health
facilities, nutritional status should be
assessed by looking and feeling for
following clinical signs:
Visible severe wasting. This is
as severe wasting of the shoulders,
arms, buttocks, and legs, with ribs easily
seen, and indicates presence of
marasmus.
Oedema of both feet. The
presence of the eodema (accumulation
of fluid) in both feet may signal
kwashiorkor. Children with oedema of
both feet may have other disease like
nephrotic syndrome; however, there is
need to differentiate these other
conditions in the outpatient settings
because referral is necessary in any
case.



288
Weight for age. When height boards are
not available in outpatient settings, a
weight for age indicator (a standard
WHO or national growth chart) helps to
identify children with low (Z score less
than-2) or very low (Z score less than-3)
weight for age who are at increased risk
of infection and poor growth and
development.
Palmar pallor. Although this clinical sign
is less specific than many other clinical
signs included in IMCI guidelines, it can
allow doctors to identify sick children with
severe anaemia often caused by malaria
infection. Where feasible, the specificity
of anaemia diagnosis may be greatly
increased by using a simple laboratory
test (e.g., the HB test).


















Classification of nutritional status and
anaemia
Using a combination of the simple clinical
signs above, a health care provider can
classify children in one of the following
categories:
 Children with severe malnutrition or
severe anaemia (exhibiting visible
severe wasting, or sever palmer
pallor or oedema of both feet) are at
high risk of death from various
severe disease and need urgent
referral to a hospital where their
treatment (special feeding, anti-biotic
or blood transfusions, etc) can be
care monitored.


- Visible severe
wasting or
- Severe palmar
pallor or
- Oedema of
both feet

SEVERE
MALNUTRITI
ON OR
SEVERE
ANAEMIA

 Children with anaemia or low (or
very low)



289
weight for age also have a higher risk of
severe disease and should be assessed
for feeding problems. This assessment
should identify common, important
problems with feeding that feasibly can
be corrected if the caretaker is provided
with effective counselling and
acceptable feeding recommendations
based on the child’s age.
When children are classified as having
anaemia they should be treated with oral
iron. During treatment, the child should
be seen every two weeks (follow- up), at
which time an additional 14 days of iron
treatment is given. If there is no response
in pallor after two months, the child
should be referred to the hospital for
further assessment. Iron is not given to
children with severe malnutrition who will
be referred. In areas
Where there is evidence that hookworm,
whipworm, and ascaris are the main
causes and contributors to anemia and
malnutrition, regular deworming with
mebendazole every four to six months is
recommend. Mebendazole is expensive
and safe in young children.
 Children who are not low (or very low)
weight for age and who show no
other signs of malnutrition are
classified as having no anaemia and
not very low weight. Because
children less than 2 years old have a
higher risk of feeding problems than
older children do. Their feeding
should be assessed. If problem are
identified, the mother needs to be
counselled about feeding her child
according to the recommended
national IMCI
clinical
guidelines (see
following
section).


- NOT (very) low
weight for age and
other signs of
malnutrition

NO ANEMIA
AND NOT
(VERY)
LOW
WEIGHT
Assessing the child’s feeding
All children less than 2 years old and all children classified as anaemia or low (or
very low) weight need to be assessed for feeding.

Feeding assessment includes questioning the mother or caretaker about: (1)
breastfeeding; (2) types of complimentary foods or fluids, frequency of feeding and
whether feeding is active; (3) feeding patterns during the current illness. The mother or
caretaker should be given appropriate advice to help overcome any feeding problems
found. (for more details, refer to the section on counselling the mother or caretaker).

The immunization status of every child brought to a health facility should be checked.
Illness is not a contraindication to immunization. In practice sick children may even be in
more need of protection provided by immunization than well children. A vaccine’s ability
to protect is not diminished in sick children.



All children under
age 2 should have a
feeding assessment,
even if they have
normal Z-score





290
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



291
not need urgent referral, check to see if the child needs non-urgent referral for further
assessment; for example, for a cough that has lasted more than 30 days, or for fever
that has lasted five days or more. These referrals are not as urgent, and other
necessary treatments may be done before transporting for referral.

Treatment in outpatient clinics
The treatment associated with each non referral classification (yellow and green) is
clearly spelled out in the IMCI guidelines. Treatment uses minimum of affordable
essential drugs (see Figure 5)

Oral Drugs
Always start with a first line drug. These are usually less expensive, more readily
available in a given country, and easier to administer. Given a second line drug (which
are usually more expensive and more difficult to obtain) only if a first line drug is not
available, or if the child’s illness does not respond to the first line drug. The health care
provider also needs to teach the mother or caretaker how to give oral drugs at home.

 Oral antibiotics: The IMCI chart shows how many days and how many times each
day to give the antibiotic. Most antibiotics should be given for five days. The
number of times to give the antibiotic each day varies (two, three or four times per
day) determine the correct does of antibiotic based on the child’s weight. If the
child’s weight is not available, use the child’s age. Always check if the same
antibiotic can be used for treatment of different classifications a child may have. For
example, the same antibiotic could be used to treat both pneumonia and acute ear
infection.
 Oral antimalarials: Oral antimalarials vary by country. Consult recommended
treatment schedules for malaria for your country.

Figure 4. Urgent pre-referral treatments for the sick child from age 2
months to 5 years.

CLASSIFICATION

Treatment
For all children before referral :
Prevent low blood sugar by giving breast milk or sugar water.
DANGER SIGN –
CONVULSIONS
If the child convulsing give diazepam (10mg/2ml solution) in
dose 0.1 ml/kg or paraldehyde in dose 0.3-0.4ml/kg rectally; if
convulsions continue after 10 minutes, give a second dose of
diazepam rectally.



292
SEVERE PNEUMONIA
OR VERY SEVERE
DISEASE
Give first dose of an appropriate antibiotic. Two recommended
choices are cotrimoxazole and amoxicillin. If the child cannot
take an oral antibiotic (children in shock or those who are
vomiting incessantly or are unconscious), give the first dose of
intramuscular chloramphenicol (40mg/kg). options for an
intramuscular antibiotic for pre-referral used include
benzylpenicillin and ceftriaxone.
VERY SEVERE FEBRILE
DISEASE
Give one dose of paracetamol for high fever (38.5°C or
above).
Give first dose of intramuscular quinine for severe malaria
unless no malaria risk.
Give first dose of an appropriate antibiotic.

SEVERE COMPLICATED
MEASLES

Give first dose of appropriate antibiotic
Give vitamin A.
If there is clouding of the cornea or pus draining from the eye,
apply tetracycline eye ointment.
SEVERE DEHYDRATION WHO TREATMENT PLAN C
If there is no other severe classification, IV fluids should be
given in the outpatient clinic according to WHO Treatment Plan
C. Give 100ml/kg IV fluids. Ringer’s lactate solution is the
preferred commercially available solution. Normal saline does
not correct acidosis or replace potassium losses, but can be
used. Plain glucose or dextrose solutions are not acceptable
for the treatment of severe dehydration.

If IV infusion is not possible, urgent referral to the hospital for
IV treatment is recommended. When referral takes more than
30 minutes, fluids should be given by nasogastric tube. If
none of these are possible and the child can drink, ORS must
be given by month.




293


Figure 5. Treatment in the outpatient health facility of the sick child from age 2
months up to 5 years

CLASSIFICATION
PNEUMONIA TREATMENT


Give appropriate antibiotic for five days.

The choice of antibiotic is bases on the fact
that most childhood pneumonia of bacterial
origin is due to Streptococcus pneumonia or
Haemophilus influenza. The treatment of non-
severe pneumonia can utilize a five-day course
of either oral cotrimoxazole or amoxicillin.
These two oral antibiotics are usually effective
Note: in areas where cholera cannot be excluded for patients
less than 2 years old with severe dehydration, antibiotics are
recommended. Two recommended choices are cotrimoxazole
and tetracycline.
SEVERE PERSISTENT
DIARRHOEA
If there is no other severe classification, treat dehydration
before referral using WHO Treatment plan B for some
dehydration and Plan C for severe dehydration. Then refer to
hospital.
MASTOIDITIS Give first dose of an appropriate antibiotic. Two recommended
choices are cotrimoxazole and amoxicillin. If the child cannot
take an oral antibiotic (children in shock or those who are
vomiting incessantly or who are unconscious), give the first
dose of intramuscular chloramphenicol (40mg/kg). Options for
an intramuscular antibiotic for pre-referral use include
benzylpenicillin and ceftriaxone.

Give first dose of paracetamol for pain.
SEVERE
MALNUTRITION OR
SEVERE ANAEMIA

Give first dose of vitamin A



294
treatment for these two bacteria, both are
relatively inexpensive, widely available, and
are on the essential drug list of most countries.
{The advantages of cotrimoxazole are that it is
used twice a day, is affordable and compliance
is good. It has been shown that with a twice-
daily dosing, compliance levels can reach 75
percent or higher. Amoxicillin almost twice as
expensive as cotrimoxazole and standard
dosages are usually given three times a day.
The compliance with three-times –a-day dosing
is about 60 percent or less.]
Soothe the throat and relieve the cough with a
safe remedy

NO PNEUMONIA –COUGH OR COLD Soothe the throat and relieve the cough
with a safe
remedy.

SOME DEHYDRATION WHO Treatment Plan B

Give initial treatment with ORS over a period of four
hours. The approximate amount of ORS
required (in ml) can be calculated by multiplying the
child’s weight (in Kg) times 75; during these four
hours, the mother slowly gives the recommended
amount of ORS by spoonfuls or sips. Note: If the
child is beast-fed, breast-feeding should continue.

After four hours, the child is reassessed and
reclassified for dehydration, and feeding should
begin; resuming feeding early is important to provide
required amounts of potassium and glucose. When
there are no signs of dehydration, the child is put on
Plan A. If there is still some dehydration, Plan B
should be repeated. If the child now has severe
dehydration, the child should be put on Plan C.

NO DEHYDRATION WHO Treatment Plan A

Plan A focuses on the three rules of home
treatment: give extra fluids, continue feeding, and
advise the caretaker when to return to the doctor (if
the child develops blood in the stool, drinks poorly,
becomes sicker, or is not better in three days).




295
Fluids should be given as soon as diarrhoea starts,
the child should take as much as s/he wants.
Correct home therapy can prevent dehydration in
many cases. ORS may be used at home to prevent
dehydration. However, other fluids that are
commonly available in the home may be less costly,
more convenient and almost as effective. Most
fluids that a child normally takes can also be used
for home therapy especially when given with food.

Recommended home fluid should be:

 Safe when given in large volumes. Very
sweet tea, soft drinks, and sweetened fruit drinks
should be avoided. These are often
hyperosmolar owing to their high sugar content
(less than 300 mOsm/L). They can cause
osmotic diarrhoea, worsening dehydration and
hypenatraemia. Also to be avoided are fluids
with purgative action and stimulants (e.g., coffee,
some medicinal teas or infusion).

 Easy to prepare. The recipe should be
familiar and its preparation should not require
much effort or time. The required ingredients
and measuring utensils should be readily
available and inexpensive.

o Acceptable. The fluid should be one that the
mother is willing to give freely to a child with
diarrhoea and that the child will readily accept.
 Effective. Fluids that are safe are also
effective. Most effective are fluids that contain
carbohydrates and protein and some salt.
However, nearly the same result is obtained
when fluids are given freely along with weaning
food that contains salt.

PERSISTENT DIARRHOEA
Encourage the mother to continue breastfeeding.
If yoghurt is available, give it in place of any animal
milk usually taken by the child; yoghurt contains
less lactose and is better tolerated. If animal milk
must be given, limit to 50ml/kg per day; greater
amounts may aggravate the diarrhoea.
If milk is given, mix it with the child’s cereal and do not
dilute the milk. At least half of the child’s energy
intake should come from foods other than milk or milk



296
products. Food that are hyperosmolar (these are
usually foods or drinks made very sweet by the
addition of sucrose, such as soft drinks or commercial
fruit drinks) should be avoided. They can worsen
diarrhea. Food needs to be given in frequent, small
meals, at least six times a day. All children with
persistent diarrhea receive supplementary
multivitamins and minerals (copper, iron, magnesium,
zinc) each day for two weeks.

DYSENTERY
The four key elements of
dysentery treatment are:
Antibiotics
Fluids
Feeding
Follow-up


Selection of an antibiotic is based on sensitivity
patterns of strains of Shigella isolated in the area
(nalidixic acid is the drug of choice in many areas).
Recommended duration of treatment is five days. If
after two days (during follow-up) there is no
improvement, the antibiotic should be stopped and a
different one used.


MALARIA Give an oral ant malarial drug. The selection of first-
line and second-line treatment for P. falciparum
malaria in endemic countries is an important
decision made by health regulating authorities (e.g.;
Ministry of Health) based on information and
technical advise provided by malaria control
programmes.
Give one dose of paracetamol for high fever (38.5º C
or above).


FEVER- MALARIA UNLIKELY Give one dose of paracetamol for high fever (38.5º
C or above).
POSSIBLEBACTERIAL INFECTION Treat other obvious causes of fever.
UNCOMPLICATED FEVER





297
MEASLES WITH OR Give first dose of Vitamin A. If clouding of cornea
or pus draining from the eye, apply tetracycline eye
ointment
MOUTH COMPLICATIONS If mouth ulcers, treat with gentian violet.


MEASLES CURRENTLY (OR Give first dose of Vitamin A.
WITHIN THE LAST 3 MONTHS)


ACUTE EAR INFECTION Give appropriate antibiotic for five days.
Give one dose of paracetamol for pain.
Dry the ear by wicking.

CHRONIC EAR INFECTION Dry the ear by wicking.

ANAEMIA OR LOW WEIGHT Assess the child’s feeding and counsel the mother
according on feeding. If pallor is present: give iron;
give oral anti malarial if high malaria risk. In areas
where hookworm or whipworm is a problem, give
mebendazole if the child is 2 years or older and has
not had a dose in the previous six months.

NO ANAEMIA NOT LOW WEIGHT If the child is less than 2 years old, assess the
child’s feeding and counsel the mother accordingly on
feeding.


 Paracetamol. If a child has a high fever, give one dose of paracetamol in the
clinic. If the child has ear pain, give the mother enough paracetamol for one day, that
is, four doses. Tell her to give one dose every six hours or until the ear pain is gone.

 Iron. A child with anaemia needs iron. Give syrup to the child under 12
months of age. If the child is 12 months or older, give iron tablets. Give the mother
enough iron for 14 days. Tell her to give her child one dose daily for those 14 days.
Ask her to return for more iron in 14 days. Also tell her that the iron may make the
child’s stools black.

Note: If a child with some pallor is receiving the antimalarial treatment using
sulfadoxine- pyrimethamine (Fansidar), do not give iron/folate tablets until a follow-up
visit in two weeks. The iron/folate may interfere with the action of the sulfadoxine-
pyrimethamine that contains antifolate drugs. If an iron syrup does not contain folate,
a child can be given an iron syrup with sulfadoxine pyrimethamine. Consult
recommended treatment charts for malaria in your country




298
 Antihelminth drug. If hookworm or whipworm is a problem in the area, an
anaemic child who is 2 years of age or older may need mebendazole. These
infections contribute to anaemia because of iron loss through intestinal bleeding.
Give 500 mg of mebendazole as a single dose in the clinic.

 Vitamin A. Vitamin A is given to a child with measles or severe malnutrition.
Vitamin A helps resist the measles virus infection in the eye as well as in the layer of
cells that line the lung, gut, mouth and throat. It may also help the immune system to
prevent other infections. Vitamin A is available in capsule and syrup form. Use the
child’s age to determine the dose, and give two doses. Give the first dose to the child
in the clinic. Give the second dose to the mother to give her child the next day at
home. Every dose of Vitamin A should be recorded because of danger of an
overdose.

 Safe remedy for cough and cold. There is no evidence that commercial cough
and cold remedies are any more effective than simple home remedies in relieving a
cough

 or soothing a sore throat. Suppression of a cough is not desirable because cough
is a physiological reflex to eliminate lower respiratory tract secretion. Breast milk alone
is a good soothing remedy.

Treatment of local infections
If the child, age 2 months up to 5 years, has a local infection, the mother or care taker
should be taught how to treat the infection at home.

Instructions may be given about how to:
 Treat eye infection with tetracycline eye ointment;
 Dry the ear by wicking to treat ear infection;
 Treat mouth ulcers with gentian violet;
 Soothe the throat and relieve the cough with a safe
remedy.






Counselling a mother or caretaker
A child who is seen at the clinic needs to continue treatment, feeding and fluids at
home. The child’s mother or caretaker also needs to recognize when the child is not
improving, or is becoming sicker. The success of home treatment depends on how
well the mother or caretaker knows how to give treatment, understands its importance
and knows when to return to a health care provider.
Eye treatment for children being referred
If the child will be referred, and the child needs treatment with tetracycline eye ointment, clean the eye
gently. Pull down the lower lid. Squirt the first dose of tetracycline eye ointment onto the lower eyelid.
The dose is about the size of a grain of rice.



299
The steps to good communication were listed earlier. Some advice is simple; other
advice requires teaching the mother or caretaker how to do a task. When you teach a
mother how to treat a child, use three basic teaching steps: give information; show an
example; let her practice. When teaching the mother or caretaker: (1) use words that
s/he understands; (2) use teaching aids that are familiar; (3) give feedback when
s/he practices, praise what was done well and make corrections; (4) allow more
practice, if needed; and (5) encourage the mother or caretaker to ask questions and
the answer all questions. Finally, it is important to check the mother’s or caretaker’s
understanding.
The content of the actual advice will depend on the child’s condition and classifications.
Below are
essential elements that should be considered when counseling a mother or caretaker:
 Advise to continue feeding and increase fluids
during illness;
 Teach how to give oral drugs or to treat local
infection;
 Counsel to solve feeding problems (if any);
 Advise when to return.
Advise to continue feeding and increase fluids:
The IMCI guidelines give feeding recommendations for different age groups. These
feeding recommendations are appropriate both when the child is sick and when the
child is healthy. During illness, children’s appetites and thirst may be diminished.
However, mothers and caretakers should be counselled to increase fluids and to offer
the types of food recommended for the child’s age, as often as recommended, even
though a child may take small amounts at each feeding. After illness, good feeding
helps make up for weight loss and helps prevent malnutrition. When the child is well,
good feeding helps prevent future illness.
Teach how to give oral drugs or to treat local infection at home: Simple steps
should be followed when teaching a mother or caretaker how to give oral drugs or treat
local infections. These steps include: (1) determine the appropriate drugs and dosage
for the child’s age or weight; (2) tell why it should be given; (3) demonstrate how to (5)
watch the mother or caretaker practice measuring a dose; (6) ask the mother or
caretaker to give the dose to the child; (7) explain carefully how, and how often, to do
the treatment at homes; (8) be used to finish the course of treatment, even if the child
gets better; (9) check the mother’s or care-takers understanding.
Counsel to solve feeding problems (if any)
Based on the type of problems identified, it is important to give correct advice about the
nutrition of the young child both during and after illness. Sound advice that promotes
breastfeeding, improved weaning practices with locally appropriate energy – and
nutrient – rich foods, and giving nutritious snacks to children 2 years or older, can
counter the adverse effect infections have on nutritional status. Specific and
appropriate complementary foods should be recommended and the frequency of
feeding by age should be explained clearly. Encourage exclusive breastfeeding for the
first four months, and if possible, up to six months; discourage use of bottles for children
of any age; and provide guidance on how to solve important problems with
breastfeeding. The latter includes assessing the adequacy of attachment and suckling.



300
Specific feeding recommendations should be provided for children with persistent
diarrhoea. Feeding counselling relevant to identified feeding problems is described in
the IMCI national feeding recommendations.
Advise when to return: Every mother or caretaker who is taking a sick child home
needs to be advised about when to return to a health facility. The health care provider
should (a) teach signs that mean to return immediately for further care; (b) advise when
to return for a follow-ups visit; and (c) schedule the next well-child or immunization visit.
The table below lists the specific times to advise a mother or caretaker to return to a
health facility.




Advise to return immediately if the child has any of these signs.
Any sick child Not able to drink or breastfeed
Becomes sicker
Develops a fever
If child has no pneumonia: Fast breathing
Cough or cold, also return if: Difficult breathing

If child has diarrhea, also Blood in stool
Return if: Drinking poorly



If the child has: Return for follow-ups

Not later than:

Pneumonia 2 days
Dysentery

Malaria, if fever persists
Fever malaria unlikely or uncomplicated
Fever, if fever persists
Measles with eye or mouth complications

Persistent diarrhea 5 days
Acute ear infection
Chronic ear infection
Feeding problem
Any other illness, if not improving


Pallor 14 days
Low (very low) weight for age 30 days
A. IMMEDIATELY
B. FOR FOLLOW-UPS VISIT



301




Advise when to return for the next immunization according to immunization schedule.

FOLLOW-UP CARE
Some sick children will need to return for follow-up care. At a follow-up visit, see if the
child is improving on the drug or other treatment that was prescribed. Some children
may not respond to a particular antibiotic or antimalarial, and may need to try a
second-line drug. Children with persistent diarrhoea also need follow-up to be sure
that the diarrhoea has stopped. Children with fever or eye infection need to be seen if
they are not improving. Follow-up is especially important for children with a feeding
problem to ensure they are being fed adequately and are gaining weight.
When a child comes for follow-up of an illness, ask the mother or caretaker if the child
has developed any new problems. If she answers yes, the child requires a full
assessment: check for general danger signs and assess all the main symptoms and
the child’s nutritional status.
If the child does not have a new problem, us the IMCI follow-ups instructions for each
specific problems:
 Assess the child according to the instructions;
 Use the information about the child’s signs to select the appropriate treatment;
 Give the treatment.
Note: If a child who comes for follow-up has several problems and is getting worse, or
returns repeatedly with chronic problems that do not respond to treatment, the child
should be referred to a hospital.
The IMCI charts contain detailed instructions on how to conduct follow-ups visits for
different diseases. Follow-up visits are recommended for sick children classified as
having:
 Dysentery
 Malaria, if fever persists
 Fever – Malaria Unlikely, if fever persists
 Measles with eye or mouth complications
 Persistent diarrhoea
 Acute ear infection
 Feeding problem
 Pallor
 Very low weight for age
 Any other illness, if not improving



NEXT WELL CHILD VISIT
C. NEXT WELL-CHILD VISIT



302






Outpatient management of young infants age 1 week up to 2 months.

Assessment of sick young infants
While there are similarities in the management of sick young infants (age 1 week up to 2
months) and children (age 2 months up to 5 years), some clinical signs observed in
infants differ from those in older children.
The remainder of this chapter covers instances where the management of young infants
differs from that of the small child. For example, it is essential to pay attention to the
following clinical signs as an infant’s illness can progress rapidly to death.

Assessment includes the following steps:

 Checking for possible bacterial infection;

 Assessing if the young infant has diarrhoea;

 Checking for feeding problems or low weight;

 Checking the young infant’s immunization status;

 Assessing other problems.

It is important to remember that the guidelines above are not used for a sick new –born
who is less than 1 week old. In the first week of life, new born infants are often sick
from conditions that related to labour and delivery, or have conditions that require
special management. New–born may be suffering from asphyxia, sepsis from
premature ruptured membranes or other intrauterine infection, or birth trauma. Or they
may have trouble breathing due to immature lungs. Jaundice also requires special
management in the first week of life.

Checking for main Symptoms Bacterial infection

While the signs of pneumonia and other serious bacterial infections cannot be easily
distinguished in this age group, it s recommended that all sick young infants be
assessed first for signs of possible bacterial infection.

Clinical Assessment
Many clinical signs point to possible bacterial infection in sick young infants. The most
informative and easy to check signs are;

Convulsions (as part of the current illness). Assess the same as for older children.

Note
Important
information on use of
oral drugs, continued
feeding, mother or
caretaker counseling,
and assessment of
immunization and
nutrition status can be
found in sections of



303
Fast Breathing. Young infants usually breathe faster than older children do. The
breathing rate of a healthy young infant is commonly more than 50 breaths per minute.
Therefore, 60 breaths per minute is the cut off rate to identify fast breathing in this age
group. If the count is 60 breaths or more, the count should be repeated, because the
breathing rate of a young infant is often irregular. The young infant will occasionally
stop breathing for a few seconds, followed by a period of faster breathing. If the second
count is also 60 breaths or more the young infant has fast breathing.

Severe Chest Indrawing . Mild chest indrawing is normal in a young infant because of
softness of the chest wall. Severe chest indrawing is very deep and easy to see. It is a
sign of pneumonia or other serious bacterial infection in a young infant.

Nasal Flaring . (When an infant breaths in) and grunting (when an infant breathes out)
are an indication of troubled breathing and possible pneumonia.

A bulging Fontanel (when an infant is not crying), Skin pustules, umbilical redness or
pus draining from the ear are other signs that indicate possible bacterial infection.

OUTPATIENT MANAGEMENT OF YOUNG INFANTS 1 WEEK UP TO 2 MONTHS
Lethargy or unconsciousness, or less than normal movement also indicates a serious
condition.
Temperature (fever or hypothermia) may equally indicate bacterial infection. Fever
(axillary temperature more than 37.5⁰C or rectal temperature more than 38⁰C) is
uncommon in the first two months of life. Fever in a young infant may indicate a serious
bacterial infection, and may be the only sign of a serious bacterial infection. Young
infants can also respond to infection by dropping their body temperature to below 35⁰C
(36⁰C rectal).

Classification of Possible infection
There are two possible classifications for bacterial infection:

 A sick young infant with possible serious bacterial infection is one who has any of
the following signs: fast breathing, sever chest indrawing, grunting, nasal flaring,
bulging fontanel, convulsions, fever, hypothermia, many or sever skin pustules,
umbilical redness extending to the skin, pus draining from the ear, lethargy,
unconsciousness, or less than normal movement. This infant should be referred
urgently to the hospital after being given intramuscular benzyl penicillin (or
ampicillin) plus gentamicin, treatment to prevent hypoglycemia, and advice to the
mother on keeping the young infant warm

 Convulsions or
 Fast breathing or
 Sever chest indrawing
or
 Nasal flaring or
 Grunting or
 Bulging fontanelle or
 Pus draining ear or





POSSIBLE
BACTERIAL
INFECTION



304
 Umbilical redness
extending to skin or
 Fever or hypothermia
 Many or sever skin
pustules or
 Lethargy or
unconsciousness or
 Less than normal
movement

A sick young infant with local bacterial infection is one who has only a few skin
pustules or an umbilicus that is red or draining pus, but without redness extending to
skin. This infant may be treated at home with oral antibiotics but should be seen in
follow up in two days.

 Red umbilicus
or draining pus
or
 Skin pustules

LOCAL
BACTERIAL
INFECTION

Diarrhoea
All sick young infants should be checked for diarrhoea.

Clinical assessment and classification of diarrhoea
Assessment, classification and management of diarrhoea in sick young infants are
similar to those in older children. However, assessing thirst by offering a drink is not
reliable, so “drinking poorly” is not used as a sign for the classification of
dehydration. In addition, all young infants with persistent diarrhoea or blood in the
stool should be referred to the hospital, rather than managed as outpatients.

Feeding problems or low weight
All sick young infants seen in outpatient health facilities should be assessed for
weight and adequate feeding, as well as for breast feeding technique.

Clinical assessment

Determine weight for age. Assess the same as for older children.

Assessment of feeding. Assessment of feeding in young infants is similar to that in
older children. It includes three main types of questions about: (1) breastfeeding
frequency and night feeds (2) types of complimentary foods or fluids, frequency of
feeding and whether feeding is active or not; and (3) feeding patterns during this
illness.





Breast feeding: Signs of good at t achment
 Ch in t ouch in g br east
 M ou t h w i de open
 Low er li p t ur ned out war d; and
M or e ar eo la vi si bl e above t han bel ow t he mou t h




305

If an infant has difficulty feeding, or is
breastfed less than 8 times in 24 hours,
or taking other foods or drinks, or has
low weight for age, then breastfeeding
should be assessed. Assessment of
breastfeeding in young infants includes
checking if the infant is able to attach, if
the infant is sucking effectively (slow,
deep sucks, with some pausing), and if
there are ulcers or white patches in the
mouth (thrush).

Classification of feeding problems or
low weight

Based on an assessment of feeding and
weight, a sick young infant may be
classified into three categories;

- Not able to feed possible serious
bacterial
infection. The young infant who is
not able to feed, or not attaching to
the breast or sucking effectively, has
a life threatening problem. This could
be a bacterial infection or another
severe illness. The infant should be
referred to a hospital after receiving
the same pre-referral treatment as
infants with possible serious bacterial
infection.


 Not able to feed
or
 No attachment at
all or
 Not sucking at all

NOT ABLE TO
FEED
POSSIBLE
BACTERIAL
INFECTION

 Infants with feeding problems or
low weight are those infants who
present with feeding problems like not
attaching well to the breast, not
sucking effectively, getting breast milk
fewer than eight times in 24 hours,
receiving other foods or drinks than
breast milk , or those who have low
weight for age or thrush (ulcers/white
patches in mouth).


 Not well attached to
breast or
 Not suckling
effectively or
 Fed fewer than 8
times in 24hours or
 Receiving other foods
or drinks or
 Low weight for age
 Thrush


FEEDING
PROBLEMS
OR LOW
WEIGHT

Appropriate counselling of the mother
should be based on the identified feeding
problem; (a) if the infant is not well
attached or not sucking effectively,
teaching correct positioning and
attachment; (b) if the infant is
breastfeeding fewer than eight times in
24hours, advise the mother to increase
frequency of feeding; (c) if the infant
receives other food or drinks, counsel the
mother about breastfeeding more,
reducing other foods or drinks, and using
a cup; (d) if the mother is not
breastfeeding at all, refer for
breastfeeding counselling and possible



306
relactation, and advise how to correctly
prepare a breast milk substitute. In
infants with thrush, teach the caretaker
how to treat thrush at home using
gentian violet. Ensure follow up for any
feeding problem or thrush in two days
and follow up low weight for age in 14
days.

 Infants with no feeding problems
are those who are breastfed
exclusively at least eight times in
24hours and whose weight is not
classified as low weight for age
according to standard measures.


 Not low weight age
and no other signs
of inadequate
feeding

NO
FEEDING
PROBLEMS


 Checking Immunization status
A for older children, immunization
status should be checked in all sick
young infants. Equally, illness is not
a contraindication to immunization.

Note: Do not give OPV 0 to an infant
who is more than 14 days old. If an
infant has not received OPV 0 by the
times/he is 15 days old, OPV should
be given at age 6 weeks old as OPV
1.

Assessing other problems

As for older children, all sick young
infants need to be assessed for other
potential problems mentioned by the
mother or observed during the
examination. If a potentially serious
problem is found or there is no means
in the clinic to help the infants, s/he
should be referred to hospital.

Treatment procedures for sick infants
Referral of young infants’ age 1 week up
to
2 months.

The first step is to give urgent pre-referral
treatments (s). Possible pre-referral
treatments include:

 First dose of intramuscular or oral
antibiotics
 Keeping the infant warm on the way
to the hospital
 Prevention of hypoglycemia with
breast milk or sugar water
 Frequent sips of ORS solution on the
way to the hospital

If an infant does not need urgent referral,
check to see if the child needs no-urgent
referral for further assessment. These
referrals are not as urgent. Any other
necessary treatment may be done before
referral.


Treatment in outpatient clinics

The treatment instructions for a young
infant are given in IMCI guidelines. The
antibiotics and dosages are different than
those for older children. Exceptions are
the fluid plans for treating diarrhoea and
the instructions for preventing low blood
sugar. WHO Plans A, B, and C and the
guidelines on how to prevent low blood
sugar are used for young infants as well
as older infants and young children.






307

Oral drugs

The first dose of oral drugs for a
young infant should always be given
in the clinic. In addition, the mother
or caretaker should be taught how to
give an oral antibiotic at home. That
is teaching how to measure a single
dose, showing how to crush a tablet
and mix it with breast milk, and
teaching the treatment schedule.

Note: Avoid giving cotrimoxazole to
a young infant less than 1 month of
age who is premature or jaundiced.
Give this infant amoxicillin or
benzylpenicillin instead.




















Figure 6. Urgent pre-referral treatments for sick young infants age 1 week up to 2
months

CLASSIFICATION
TREATMENT



For all infants before referral:



Prevent low blood sugar by giving breast milk or sugar
water.
Advise mother how to keep the infant warm on
the way to the hospital



CONVULSIONS
If the child is convulsing, give diazepam (10 mg/2 ml
solution) in
dose 0.1 ml/kg or paraldehyde in dose 0.3 – 0.4 ml/kg
rectally; if convulsions continue after 10 minutes, give a
second dose of diazepam rectally. Use Phenobarbital (200
mg/ml solution) in dose of 20 mg/kg to control convulsions in
infants under 2 weeks of age.




308


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











309
FEEDING PROBLEM OR LOW WEIGHT
Give appropriate feeding advice.


If thrush, teach the mother to treat thrush at home.


Treatment of local infections

There are three types of local infections in a sick young infant that a caretaker
can treat at home: an umbilicus that is red or draining pus, skin pustules, or
thrush. These local infections are treated with gentian violet.

Counselling a mother or caretaker

As with older children, the success of home treatment depends on how well the
mother or caretaker knows how to give the treatment, understands its
importance, and knows when to return to a health care provider.

Counselling the mother or caretaker of a sick young infant includes the following
essential elements:

 Teach how to give oral drugs or to treat local infection.

 Teach correct positioning and attachment for breastfeeding:
a) Show the mother how to hold her infant
b) With the infant’s head and body straight
c) Facing her breast, with infant’s nose opposite her nipple
d) With infant’s body close to her body
e) Supporting infant’s whole body, not just neck and shoulders.

 Show her how to help the infant to attach. She should:
a) Touch her infant’s lips with her nipple
b) Wait until her infant’s mouth is opening wide
c) Move her infant quickly onto her breast , aiming the infant’s lower lip well
below the nipple.

 Look for signs of good attachment and effective suckling. If the
attachment and effective suckling is not good, try again.

 Advise about food and fluids : advise to breastfeed frequently, as often as
possible and for as long as the infant wants, day and night during sickness
and health.

 Advise when to return:






310



Advise to return immediately if the infant has any of these signs:

 Breastfeeding or drinking poorly

 Becomes sicker

 Develops a fever

 Fast breathing

 Difficult breathing

 Blood in stool



If the infants have: Return for follow-up

. not later than:


Local bacterial infection
Any feeding problem 2 days
Thrush

Low weight for age 14 days




Advise when to return for the next immunization
according to immunization schedule.
Follow-up care
If the child does not have a new problem, use
The IMCI follow-up instructions for each specific problem:
 Assess the child according to the instructions;
 Use the information about the child’s signs to select the appropriate
treatments;
 Give the treatment.
IMCI charts contain detailed instructions on how to conduct follow-up visits for
different disease. Follow-up visits are recommended for young infants who are
classified as:
 Local bacterial infection
 Feeding problems or low weight (including thrush).

A. IMMEDIATELY
B. FOR FOLLOW-UPS VISIT
C. NEXT WELL-CHID VISIT



311

CHAPTER 23

Approaches to Improve Quality of Services for Hospitalized Sick
Children

Stephen N. Kinoti

INTRODUCTION
More than 11 million children worldwide die each year, mainly in developing countries
due to common and treatable illnesses. Interventions to reduce child mortality have paid
little attention to the district hospitals and other facilities providing inpatient care, where
the sickest 20% of children are cared for but quality of care is often poor. Led by WHO’s
Department of Child and Adolescent Development (CAH), the initiative has many facets,
including a study that assessed 21 hospitals providing paediatric care in seven less-
developed countries.
i
The study (hereafter “Nolan study”) found that 12–34% of sick
children under five who visit health facilities need hospital care. The hospitals exist,
albeit for many children, perhaps half, these hospitals are too far from home.
Nevertheless, if extant paediatric hospitals and paediatric departments of secondary
and tertiary service hospitals were performing optimally, they could save many
children—or spare them immeasurable suffering. The Nolan study found that 14 of the
21 hospitals lacked an adequate system for triage (both assessment and quick
treatment) and that most emergency treatment areas were poorly organized and lacked
necessary supplies. In addition, poor case management (assessment, treatment, and
monitoring) occurred in 76% of hospitalized children. Last, staff had inadequate
knowledge for managing childhood illnesses. The study interpreted these findings as
indicating that “strengthening care for sick children referred to hospital should focus on
achievable objectives with the greatest potential benefit for health outcome. Possible
targets for improvement include initial triage, emergency care, assessment, inpatient
treatment, and monitoring. Priority targets for individual hospitals may be determined by
assessing each hospital.”


“One of many tragic events: In 2004, three other paediatricians, seven medical
officers, 10 nurses and I entered a developing country paediatric ward just as a
gasping 5-year-old was being admitted. We had come to prepare for practical
training in Emergency Triage, Assessment and Treatment (ETAT), which was not
yet established in this hospital. We could not save the child: There was no
oxygen; no emergency tray nor emergency drugs; the medicine cabinet was
locked and the key was not immediately available; no airways, no ambu-bag nor
endotracheal tubes, essentially no resuscitation equipment or medicines were
available. The child was bleeding from cracked lips. He died right there in front of
all of us, and there was nothing we could do. We needed more than skilled staff.
We needed equipment, drugs and other supplies. When you have an experience
like that, it really drives home the fact that skilled human resources are not all
that is needed. To have a hospital that is not basically equipped and has no
emergency response system in place is not just a tragedy for the patients



312
involved, it’s a waste of the investment made in creating and staffing the
hospital,” personal communication, Stephen Kinoti
ii


LEARNING OBJECTIVES
At the end of this chapter the student will be able to:
Define quality of care;
Explain the factors which determine and influence quality of care
Understand some of the approaches that can be applied to improve quality of services
for seriously ill children
Describe the role of team work in improving quality of services
Describe the scientific basis of modern improvement methods
Identify ways in which he or she could contribute to the quality improvement process
Understand the principle of change and measurement of change as key elements of
modern improvement theory and practice

LEARNING ACTIVITIES
Participate in the adaptation to a national or institutional situation, standards of care for
seriously ill children from internationally accepted standards.
Being part of ensuring the standards of care are available at the care facilities, are well
understood, and available in simplified forms that they can service as job aids when
needed to save lives
Participate in setting up response systems, patient flow processes and procedures that
increase system efficiencies and eliminate redundancies
Participate as a membership of multidisciplinary quality improvement teams
Actively participate in planning, doing, testing and acting (PDSA) on changes that are
found to work and help institutionalize them into routine procedures of work.
Regularly participate in sharing best practices with other teams in other facilities so that
ultimately, the institution, the health system and the country is transformed into a
community of best practice.

What is quality health service?
Quality care is what happens at all the points of service along the continuum of care,
and high quality care is a function of the system's ability to produce care that will
address the client's needs in an effective, responsive and respectful manner, personal
communication, Dr. David Nicholas
iii
, former director of United States Funded Quality
Assurance Project, 2008.
Quality comprises three elements:
Structure refers to stable, material characteristics (infrastructure, tools, technology) and
the resources of the organizations that provide care and the financing of care (levels of
funding, staffing, payment schemes, and incentives).
Process is the interaction between caregivers and patients during which structural
inputs from the health care system are transformed into health outcomes.
Outcomes can be measured in terms of health status, deaths, or disability-adjusted life
years—a measure that encompasses the morbidity and mortality of patients or groups
of patients. Outcomes also include patient satisfaction or patient responsiveness to the
health care system (WHO 2000
iv
).



313
Deficiencies in quality of care represent neither the failure of professional compassion
nor necessarily a lack of resources (Institute of Medicine 2001
v
). Rather, they result
from gaps in knowledge, inappropriate applications of available technology (Murray and
Frenk 2000
vi
), or the inability of organizations to change (Berwick 1989
vii
). Local health
care systems may have failed to align practitioner incentives and objectives, to measure
clinical practice, or to link quality improvement to better health outcomes.
In recent years the concept of quality has been expanded to include specific aims for
improvement. For example, the Institute of Medicine's (2001
viii
) 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 2002
ix
). 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.




314
Figure 1: The The Framework for Clinical Framework for Clinical
Quality Improvement Quality Improvement
Content of Care Content of Care
Evidence Evidence- -based based
• •Standards Standards
• •Protocols Protocols
• •Guidelines Guidelines
Traditional Traditional
Quality Improvement Quality Improvement
Adapted from: Paul Adapted from: Paul Batalden Batalden, Patricia , Patricia Stoltz Stoltz
A Framework for Continual Improvement in Healthcare A Framework for Continual Improvement in Healthcare
Joint Commission Journal on Quality Improvement Joint Commission Journal on Quality Improvement
October 1997 October 1997
Process of Care Process of Care
Quality Improvement Quality Improvement
Methodology Methodology
Continuous Continuous
Quality Improvement Quality Improvement
=
=


Application of proven standard guidelines

WHO commissioned a study of small hospitals in 1997 that would become known as the
seven-country study (Bangladesh, DR, Ethiopia, Indonesia, Philippines, Tanzania, and
Uganda) (WHO CHD 1998
x
). The results were published in The Lancet January 2001
(Nolan et al. 2001
xi
). 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 RCM
xii
. The CHD of WHO noted that the
guideline would also provide the technical foundation for improving quality of care in
referral facilities (WHO CHD 1998). This took care of the content of care in the
framework for quality improvement an essential component but not sufficient to
intervention for higher level of care. This content has been disseminated widely and
used in the 11 days IMCI training, the reduced 6day course and even put into interactive
computer based training formats. It has become clear that the process of care needs to
be improved as well.

Improving processes of care
A fundamental concept of improvement as described by Paul Batalden
xiii
is that, “Every
system is perfectly designed to get exactly the results it gets”. This leads to the
conclusion that for improvement to occur there must be a change and for one to know
that the change is an improvement, the change must be measured. A major problem in
many developing counties is the lack or limited culture of measurement to monitor
changes in processes and outcomes of care. It also implies that to bring about change,
service providers must be aware of where they are, what the system is doing currently,
make an hypothesis that a certain changes made in the system will lead to an
improvement, implement the change, measure the outcome and determine whether
there was an improvement or not. This is what is referred to as the Plan. Do, Study, Act,



315
the PDSA cycle of testing changes and if they prove effective, acting to institutionalize
them into routine practice. The following is a model for improvement:
IDENTIFY: What are we trying to
accomplish?
ANALYZE: How will we know
That a change is an improvement?
DEVELOP: What changes can we make
That will result in improvement?
Model for Improvement
Act Plan
Study Do
Steps
1-3
Step 4
Testing
changes



An example of the use of the model for improvement and the PDSA cycles to reduce
waiting time for laboratory results: Gives current practice and changes that were tested
to lead to an improvement.

Current Practice–Clinician collects samples at OPD, places it in a container in OPD;
laboratory technician collects the samples once daily from OPD, works on them and
sends back results back following day, a 24 hours wait!!

1st PDSA Cycle
Plan OPD staff take samples to lab, lab works on it and sends back by internal delivery
system
OPD Staff take samples to lab, lab works on it and sends back by internal delivery
system results back
Results are received back in 6-8 hours
Study. Some little improvement but not good enough
Plan more improvement in the 2nd cycle
2nd PDSA cycle
Plan for OPD staff take samples to lab and asks the lab tech to bring back the results
Staff take samples to lab and asks the lab tech to bring back the results
The Lab tech returns results in 4 hours
Study---Better but not best
Plan more improvement in the 3rd cycle
3rd PDSA cycle
Plan to set up small lab in OPD on a trial basis, to equip and staff lab and measure time
taken to receive results
Small lab in OPD on a trial basis, to equip and staff lab and measure time taken to
receive results



316
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 Malenga
xiv

1998, in which they state,

“The introduction of forms called critical care pathways into the pediatric unit of a
hospital in Malawi has strengthened team work, helped to increase the efficiency with
which resources are employed. They serve the dual function of indicating good
management and providing an opportunity to note actions and potential progress.”

Certification and accreditation
During this era of HIV/AIDS, health facilities both private and public sector have to be
certified or accredited before they can provide ART and PMTCT services. Some of the
criteria that have been used have included:
Availability of guidelines of care that are adapted to the local settings in the health
system of the country for each level of care
Trained staff in AIDS care The ART/PMTCT program required that regional referral
hospitals capacity to train and service lower health facilities was strengthened, clinical
teams in each facility comprising of 1 medical, 1 clinical officer, 2-3 Nurses, 2-3
Counselors, pharmacist/ dispenser , lab person and strengthened referral network
across a continuum and improved coordination.
Available or easily accessible VCT services
Available space for patient counseling and assessment that ensures reasonable
confidentiality including those for children
Functioning laboratory services that can conduct basic and minimum investigations as
outlined in the national ARV treatment guidelines including facilities for testing or
screening infants before they are 18 months old
ARV drugs procurement and safe storage systems including Paediatric formulations
Health management information system (HMIS) where proper records are kept for
tracking patients on ART/PMTCT and on treatment of opportunistic Infections
Follow- and referral system including arrangements for consultations with other
ART/PMTCT centers



317
If the facility which could a hospital or health center is found short of the required level
arrangements are made to support, strengthen the facility to improvement its capacity in
each area of deficiency using quality improvement approaches such as training ,
coaching, testing improvement changes, measuring improvements and reassessments.

Pay for performance
In the USA, Pay-for-Performance programs have been shown to improve both medical
care and quality of life by giving health care providers a financial incentive to seek
measurable improvements in the health of their patients. The findings, released at a
National Press Club briefing, are the combined result of seven experimental projects
designed to test a variety of pay-for-performance models known as the Rewarding
Results program, the three-year effort is both the largest and most diverse of its kind.
The projects "provide some of the first tangible evidence that (Private for Profit” (PFP)
incentives can raise the quality of patient care," says Suzanne Delbanco, CEO of the
Leapfrog Group
xv
.The examples of recent P4P research and tools supported by the
Agency for Healthcare Research and Quality (AHRQ) provide further evidence for
possible value of Pay for performance which must be tailored to deferent settings to
different country settings.
According to Louis Rusa, (National PBF Coordinator-Ministry of Health Rwanda), and
Gyuri Fritsche
xvi
, (Health Care Financing Specialist-Management Sciences the Rwanda
performance-based financing in health has demonstrated improved performance by the
health care system that can serve as guide to similar schemes. Essential elements in
the success in Rwanda were the roll out and strong consistent leadership at the highest
level in the ministry of health. The key premise in output-based aid is that it “seeks to
address weaknesses by delegating service delivery to a third party under contracts that
link payment to the outputs or results delivered. It thus has the potential to improve
incentives and accountability, while also expanding opportunities for mobilizing private
financing. The focus shifts not only from inputs to outputs, but also toward the Holy Grail
of development outcomes” as presented in: “Contracting for public services; Output-
based aid and its applications”, WB/IMF 2001, Page 91.

Measuring process of service delivery
Technical advances have mitigated longstanding difficulties in measuring process. Five
approaches and their strengths and weaknesses merit consideration: chart abstraction,
direct observation and recording of visits, administrative data, standardized patients,
and clinical vignettes. I will review these as possible options for measuring processes
improvements.
Chart Abstraction
Chart abstraction, or review of the medical record, has long been used to measure
technical quality. Such familiar quality evaluations as clinical audits, physician report
cards, and profiles are based on chart abstraction. The core strength of the medical
record is that it is ubiquitous and can generally be obtained after each encounter. Chart
reviews, however, suffer from problems of legibility when notes are handwritten. Often
they are generated for reasons other than recording the actual events of the clinical visit



318
(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 2000
xvii
). In a related analysis,
6.4 percent of the items recorded in the chart were false and had never really occurred.
Nonetheless Yawn and Wollan
xviii
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 2004
xix
). The great
heterogeneity in record-keeping practices, problems with medical records (both paper
and electronic), and costs of trained medical abstractors have led to a search for other
reliable ways to measure quality.
Direct Observation and Recording of Visits
Direct observation and recording of visits is a commonly used approach in developing
countries. Ethically, the provider and the patient must be informed of the observation or
recording, which introduces participation bias because provider behavior may change
as a result of being evaluated. In addition, trained observers are costly, and variation
between observers is difficult to remedy. Himle, Chang and Woods et al
xx
, suggest that
clinical behavior analysts do not abandon direct observation in favor of other
measurement techniques, rather, call to behavior analysts to develop, investigate, and
incorporate new direct and indirect measurement techniques that will enhance scientific
investigation of the environment–behavior relations involved in clinical problems.
Administrative Data
Administrative data, collected for purposes of managing the delivery of care, are
available in all but the poorest settings. A data collection system, once established, is
ubiquitous and can provide information on charges and many cost inputs. Administrative
data, however, lack sufficient clinical detail to be useful in evaluating process. In a 2003
study, an incorrect diagnosis was recorded in the data 30 percent of the time (although
the diagnosis was made correctly). Overall, these data reflected the actual clinical
diagnosis only 57 percent of the time (Peabody, Luck, Jain, and others 2004
xxi
). 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.






319
Standardized Patients
Standardized patients can be a gold standard for process measurement (Luck and
Peabody 2002
xxii
). Trained to simulate illness, standardized patients present themselves
unannounced into a clinical setting to providers who have previously given their consent
to participate in the study. At the conclusion of the visit, the standardized patient reports
on the technical and interpersonal elements of process. Standardized patients are
reliable over a range of conditions and provide valid measurements that accurately
capture variation in clinical practice among providers over time. However, they are
expensive and useful only for adult conditions and only those conditions that can be
simulated. Thus, they are not practical for routinely evaluating quality.
Clinical Vignettes (typical description of a condition)
Clinical vignettes were developed explicitly for measuring quality within a group of
providers and evaluating quality at the population level. Vignettes are responsive to
variation in quality, and providers readily accept them if they are given anonymously
(Peabody, Luck, Glassman, and others 2004
xxiii
). More than 20 vignettes have been
used in 13 countries around the world. They can be administered on paper, by
computer, or over the Internet. Providers are typically presented with several cases.
When process is being measured for many providers, each provider is presented with
the same case or set of cases, thus eliminating the need for case-mix adjustment. The
provider completing the vignette is asked to take a history, do an examination, order the
necessary tests, make a diagnosis, and specify a treatment plan. The questions are
open ended and include interactive responses that simulate the visit and evaluate the
physician's knowledge. In two separate, prospective validation studies among randomly
selected providers, vignettes consistently demonstrated greater predictive validity of
process than did the abstracted medical record. Vignettes have been validated against
the gold standard of standardized patient visits, and they reflect actual clinical practice,
not just physicians' knowledge. Vignettes have several other advantages. Because
exactly the same case can be given to many providers, vignettes are useful for
comparison studies. They are also useful for pre- and post evaluations of policy
interventions designed to improve quality. Finally, they are inexpensive to administer
and straightforward to score, making them particularly useful in developing countries.
Improvement Collaborative Approach

Growing evidence suggests that the Improvement Collaborative approach has been
shown to increase compliance with standards of care for seriously ill children
xxiv
and to
lead to better outcomes in a number of countries including Malawi, Nicaragua, Niger
and Eritrea in Africa, and Nicaragua in Latin America. Partners in the implementation of
these collaboratives included UNICEF, WHO, Care International, Pan American
Organization and Ministries of Health in the participating countries.

An Improvement Collaborative
xxv
(developed by the Institute for Health Improvement in
Boston, Massachusetts, USA) is an organized effort of shared learning by a network of
teams to:



320
• Adapt to their local situations a known, best practice model of care for a priority health
problem
• Achieve significant results in a short period, i.e., 12-24 months, reducing the gap
between best and current practice
• Scale up the adapted model throughout the organization using an intentional spread
strategy

Thus, improvement collaboratives seek to adapt and spread existing knowledge (e.g.,
best practices, evidence-based guidelines) to multiple settings. An improvement
collaborative is made up of 20-40 teams from different organizations or geographic
regions that are all focused on making rapid incremental improvements in a single
technical area and committed to working and learning together intensively for 12 to 18
months. The collaborative engages the teams in working out the operational details in
implementing known best practices in their respective settings. A collaborative can
achieve dramatic improvements in the quality and outcomes of care in a short period of
time by monthly tracking of the pace of improvements and active sharing of strategies
for improvement of services between participating teams. A collaborative is often
followed by a second phase, often known as an expansion collaborative, that provides a
framework for spreading the improvements from the initial or demonstration site to the
rest of the parent health system.

Basic Principles of Improvement Collaboratives
A collaborative is organized around a specific topic. The program or organizational
leaders who sponsor the collaborative begin with a health care issue that is important to
them, such as Pediatric Hospital care, tuberculosis case management or prevention of
mother-to-child transmission of HIV. Such a topic encompasses both evidence-based
clinical care and the organization of services to meet the needs of patients, including
issues of wasted resources, community links, and health policies.
1.
2. Expert knowledge about the topic is assembled and made available to
participants in a readily usable form. Since new ideas for changes to existing
systems are usually required to make improvements, the first step in the
collaborative process is to research and organize the relevant knowledge of the
topic and make it easily available to collaborative participants. This is often done
through an expert meeting, which brings together content experts and those with
experience in implementing best practices to define the set of key changes that
need to be made in a facility to achieve desired levels of service quality for the
chosen topic. These ideas are organized in a set of improvement objectives
sometimes referred to as a “change package” which provides collaborative
participants concrete ideas that they can then test and adapt in their local
settings.

Emphasis on rapid testing of changes: One difference with traditional process
improvement efforts is that in a collaborative, teams are encouraged to continuously test
changes, often on a very small scale and in a short period of time, and then apply that
learning on increasingly larger scale: start small, quickly, and learn from each test
(“What change can you introduce by next Tuesday with two patients?”). What works on
a small scale is then applied on a larger scale and adapted as needed to expand



321
application and continually improve results. Monthly tracking of the collaborative’s key
measurement indicators keeps teams focused on results.

An improvement collaborative creates a “community of practice” focused on
achieving results in a short period of time. Collaboratives are designed to provide a
critical mass, usually 10 to 30 teams, that is large enough to create a wide range of
ideas for how to improve the selected service, but small enough to constitute a peer
group. The teams exchange experiences frequently, through meetings, e-mail,
telephone or internet-based communications, and brief written reports. Coaching visits
from the organizational unit sponsoring the collaborative also facilitate the sharing of
experiences across teams. The collaborative seeks to make each team familiar with the
work of the other teams, with what efforts were successful, and which were not. This
interested peer group provides an intangible but important incentive to keep records,
report regularly, and contribute actively to the overall goals of the group.

Collaboratives seek to create a culture among participants where everyone learns and
everyone teaches, with friendly competition and urgency to action. Health systems in
developing countries are often viewed as static. Known deficiencies in quality of care,
such as missed opportunities for immunization, persist with no response. Ineffective
processes, such as the referral of the sickest patients, are widely recognized as
deficient, but typically providers do not feel a sense of urgency or a mandate to improve
them. In a collaborative, participants are motivated to participate by the attraction of
being part of a focused, national or international effort; by the desire to apply the latest
scientific or medical knowledge; and by the sense of competing with other teams to
show the greatest improvement. The facilities that join a collaborative usually do so
voluntarily, out of interest in improving an element of care. If there is an administrative
mandate to participate, the senior managers are responsible for making the work of the
collaborative attractive for the teams.

Collaboratives use several mechanisms for learning and changing current
practices, chiefly mutual learning by peers. In some cases, clinical training is needed
to develop capacity to apply new standards of care (e.g., emergency, triage assessment
and treatment) but most improvements involve changes in the way health care is
organized. The improvements shown in the PHI collaborative in Niger did not result from
simply conducting a training course. Rather, each of the participating teams studied how
ETAT was implemented, identified specific obstacles to complying with national
standards for emergency care, and tested different ideas to improve performance. The
premise is that external improvement or content experts can facilitate the collaborative,
but it is regular health workers who identify how solve local problems. Key clinical and
nursing staff from the facilities were identified and trained in clinical care using standard
WHO guidelines adapted to the country situation, and in the use of standardized tools to
monitor case management and outcomes of care. Mentoring was provided by
collaborating partners’ on a regular at basis using standardized tools to monitor systems
improvements and outcomes of care and compliance with standards

While each PHI Collaborative addressed emergency triage assessment and treatment
and adaptation of WHO referral care guidelines, additional activities addressed specific
problems:



322

• Nicaragua included an emphasis on essential newborn care, neonatal resuscitation,
and prevention of mother-to-child transmission of HIV.
• Niger addressed nutritional recuperation of severely malnourished children in 15 sites.
• Tanzania emphasized improving pediatric AIDS care.

At the start of each collaborative, teams self-assessed their care and then began
introducing site-specific improvements.

Teams met 4-6 times over three years to acquire new knowledge and skills and share
experiences in implementing changes. They also received periodic coaching visits by
local experts. High-performing teams provided peer coaching to slower ones. Teamwork
and coaching help institutionalize the process, create local ownership, and facilitate
faster spread of improvements.

Illustrative Results

Key areas of pediatric service with specific improvements introduced by teams
participating in improvement collaboratives
National clinical standards and guidelines
National clinical standards and guidelines
Adapted international clinical standard guidelines (WHO Referral Care Manual) to
national situation
Trained staff in the use of the Referral Care Manual
Displayed chart booklets and laminated charts to remind staff of the Manual’s guidelines
while they worked
The Manual is available in all service areas
Emergency triage, assessment, and treatment
Designated triage personnel to undertake triage immediately on arrival of ill child
Instituted triage assessment 24 hours, 7 days a week
Designated emergency care areas and fully stocked emergency trays with drugs and
equipment
Assigned escorts to very sick patients
Introduction and use of job aids
HIV screening algorithm in all child care service areas, including outpatient department,
maternal and child health clinics, wards
Charts from Referral Care Manual in all care areas
Counseling cards for prevention of mother-to-child transmission of HIV in Antenatal
Care and HIV Counseling and Testing Centers
Infant and child nutrition guidelines in the recuperation and malnutrition wards/units
Reducing waiting time
Documenting arrival and discharge times for patients (to monitor duration of stay)
Escorting those who are very sick to care areas
Calling and informing wards of incoming patients
Bringing lab services to outpatient departments
Using rapid diagnostic tests
Improving patient flow at each provider-patient contact
Monitoring compliance with standards of care and treatment



323
Introducing critical care pathways or care monitoring charts for all admitted patients
Reviewing case notes every month for major common conditions
Death audits on all deaths monthly
Monitoring trends in mortality and case fatality monthly
Improving referral systems
Mapping of referral networks throughout the continuum of care
Developed referral forms and guidelines
Work with community-based organizations to improve linkages between facilities and
community services
Each service area represented on the Quality Improvement team
Baby and child friendly services
Toys and other stimulation equipment available
Collaborative sites certified and recertified as baby and child friendly
Rooming-in services for newborns and their mothers
Increasing availability of commodities and essential drugs
Regular use of reporting and requesting (R&R) system to avoid stock-outs
Maintaining an up-to-date inventory of commodities, drugs, and equipment
Daily use of check lists at handover
Inclusion of pharmacy and procurement staff on the hospital Quality Improvement team

Illustrative results
The illustrative results of aggregated data from Tanzania, Niger and Nicaragua are
presented below in the form of time series charts two showing improvements in
compliance with standards of care and one showing improvements in outcomes of care
over the life of the collaboratives in months for demonstration sites and for new spread
sites. Figure1 shows the percentage of children who were triaged upon entry to the
hospital in Niger and Tanzania.
Figure 1: Percentage of Children Who Were Triaged upon Entry to the Hospital in
Niger and Tanzania (2003-2007)




324


Figure 2 shows that in both Niger and Nicaragua the trend is an improvement of
children presenting with emergency conditions who were treated according to norms.
Figure 2: Correct Treatment/Case Management of Children Seen in the Emergency
Room in Niger and Nicaragua (2003-2007)



Figure 3: Correct Case Management of Pneumonia in Nicaragua, Niger, and Tanzania
(2003-2007)



In all three countries, the trends are that there was improved care for severe pneumonia
in Nicaragua, increased proportion of children treated correctly for Pneumonia in
Tanzania and proportion of children treated for pneumonia according the standard



325
norms in demonstration and spread sites. Figure 4 shows reduction in case fatality
among malaria, Pneumonia and HIV/AIDS cases in Tanzania
Disease specific Case Fatality Rates in 5 demostration sites in children with HIV,Maralia and Pneumonia
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Months
C
a
s
e

F
a
t
a
l
it
y

R
a
t
e
(%
)
Malaria.Demo 12 12 10 8% 6% 7% 6% 6% 7% 10 12 9% 9% 12 13 6% 7% 4% 4% 6% 5% 5% 9% 6% 8% 8% 6% 6% 4% 4% 4% 5% 5% 8% 7% 5% 3%
Pneumonia. Demo 20 23 14 16 17 17 10 12 16 9% 11 12 17 13 16 11 9% 12 14 14 15 15 17 15 14 12 9% 8% 7% 9% 8% 10 11 15 18 10 12
HIV. Demo 28 42 10 14 20 41 30 30 30 19 24 29 19 16 17 21 13 18 17 21 4% 11 19 23 22 19 21 8% 14 10 12 21 8% 16 6% 18 26
F
05
M A M J J A S O N D
J
06
F M A M J J A S O N D
J
07
F M A M J J A S O N D
J
08
F

Conclusions
A number of quality improvement options have been tried in many countries both in the
developed and developing countries with various degrees of success. Over time
however, it has become clear that these different options have a role to play in bringing
about improvement in systems of care and outcomes of care. The improvement
collaboratives have been used extensively in developed countries and are taking root in
developing countries and have contributed to improving the quality of pediatric services
in first referral hospitals.

Significant improvements in patient flow and triage have been set up, special areas for
very sick children have created such as emergency rooms and spaces equipped with
emergency trays and drugs, oxygen concentrators and means of resuscitation provided.
Compliance with standards of care has improved by a range of 30%-50%; case fatality
came down by about 15-30% among the most difficult situations and by about 50% in
the more affluent countries all in a short period of time and with little financial
investment. Staff morale has significantly improved in all the PHI countries.

Other system improvements include the application of standard care and treatment
guidelines, building capacity of providers in continuous quality improvement, and
monitoring changes in care quality over time. Improvements achieved in demonstration
sites have been spread to new sites, where improved outcomes have been achieved
more rapidly than in the original sites. The collaborative approach by combining a
number of other improvement methods is not the only way but an effective way to
introduce standards of care, apply them, and rapidly increase compliance with these
standards leading to improved outcomes of care.







326
CHAPTER 24


NATIONAL HEALTH SECTOR REFORMS
AND HEALTH CARE FINANCING

Esther D. Mwaikambo, Stephen Kinoti, Amos Odiit, Samuel Ayaya

1.0 INTRODUCTION
Equal access to health care is accepted as a right and this was endorsed by member
states of WHO in the Alma Ata Declaration (WHO/UNICEF 1978) with commitment to
the target of health for all by the year 2000. Since then, many achievements have been
made in terms of health infrastructure, health service delivery, and human resource
development in the health sector. Due to inadequate allocation of financial resources by
many governments to the social sector, particularly to the health sector, alternative
methods of financing health Services had to be developed. Other broad areas included
within health reforms are: human resource development, quality assurance,
decentralization, integration of services, health information management and research.
At this time when most countries in Sub-Saharan Africa (SSA) are instituting health
reforms, all health workers particularly medical doctors need to be knowledgeable in all
aspects of health reforms formulation and implementation.

1.1 Need for Health Sector Reforms
Following the World development report 1993 and the subsequent World Bank report:
“Better Health in Africa 1994,” many countries in Sub Saharan- Africa are undertaking
health sector reforms. The major identified problems include:
- inadequate resources for the health sector;
- inadequate managerial capacity at all levels especially at the district level
including lack of supervision and lack of motivation;
- the growing gap in knowledge between the community and public health
providers;
- poor implementation of programs leading to poor quality of care including
dependence on donor funding for basic health programs;
- inadequate human resources and poor human resources management;
- lack of clear policies in relation to integration of services;
- need for decentralization;
- lack of an appropriate research priority policy.

It has become necessary therefore for countries to develop a comprehensive health
reform framework.

2.0 OBJECTIVES
At the end of this chapter the student will be able to:

- Describe government financing of health sector in your country
- Describe the alternative health financing systems in his/her country;



327
- Describe human resources necessary to provide quality child health care
services at the health center level;
- Estimate the cost of providing such a service;
- Describe the integrated management of common childhood and maternal
illnesses including family planning;
- Plan the evaluation and monitoring of services provided to children at a health
facility;
- Describe health information needs at various levels of the health care system;
- Identify research needs at various levels of health care with respect to child
health.
- Describe the available clinical protocols and guidelines at the health facility for
specific health service management.

3.0 LEARNING ACTIVITIES
- Visit a health center and describe staffing level and adequacy in respect to the
services being provided to children.
- Write a report on the adequacy of equipment, supplies and drugs at the facility.
- Visit and acquaint yourself with Health Sector Reform Unit, and write report on
how current health reforms address the health needs of children in your country.
- Visit a health center and work out the cost of providing various services, such as
drugs, laboratory supplies, personnel, transport, and building maintenance.

4.0 Efficient Use of the Allocated Resources
Efficient use of the allocated resources means that there should be improved and better
services without additional resource allocation. Such resources should be directed to
services that have a multiplier effect and are accessible to the majority of the
population. For example: immunization of children, treatment of common childhood
illnesses such as diarrhea and acute respiratory infections (ARI), treatment of malaria,
tuberculosis, maternal and child health and family planning services.

5.0 Financing in the Health Sector Reform
The financing of health care services has profound influence on the quality, quantity and
equity of health services. For many years and until health sector reforms have been
instituted in most countries, governments have been the main financier of health
services with support from donor countries. Apart from the public sector financing the
current reforms, should develop various alternative financing options.

UNICEF advocates that all governments should allocate at least 20% of their national
budgets to the social sector, especially to Health and Education (the 20/20 principle).
This can be easily done by reducing on military spending.

5.1 Alternative Financing

5.1.1 Health Insurance Schemes
In addition to other sources of financing, many countries in the region are currently
developing national health insurance schemes which will initially cover the formal sector
of employment and provide a wide range of health services at low cost to the users.



328
Some countries in East Africa have started health insurance schemes for their
employees and this seem to be working well. Many private health insurances schemes
have also being established and a few people have joined them. However the majority
of the Africans especially the grass-root people from the rural and urban areas are still
without health insurance. Health care financing for these people is still a major
challenge.

5.1.2 Cost Sharing
Cost sharing in the form of user-charges is another source of financing that has been
introduced in the health reform as a supplementary financial option in improving the
deteriorating condition of health services. Cost sharing has been introduced in most
East African countries in the past several years. Initially there was a lot of resistance to
the programme but now slowly people are accepting the reality. Everybody is expected
to contribute a small amount of money for the services. Exempted are children below 5
years and people with chronic illnesses.

5.1.3 Private medical services
There are three modalities of private medical services:
- Private medical services within public medical facilities
- Private not for profit services such as those provided by some faith based
organization
- Private for profit medical services such as those provided by individual
practitioners and other organizations.

In many countries in the region, private medical services within the public medical
facilities are used to help generate supplementary funds for the public health facility.

5.1.4 Community financing
In the current health sector reform, community financing is suggested as an alternative
method of raising revenue at the community level. Community financing is part of
community participation and one of the principles of the Alma Ata declaration. It is used
to generate or increase awareness of health leading to greater demand and utilization of
health services.

Community financing schemes such as the Bamako Initiative schemes are already
being implemented successfully in several countries with full community participation.
The communities themselves have established criteria on who should be exempted
from paying fees, such as the very young and elderly. Revenues from such payments
can then be used to promote health services in the area. Community financing can be in
form of: giving cash, labor, or other provisions from which no single individual benefits,
but the whole society. Tanzania introduced community health financing several years
back. The programme has been well accepted in the three districts of Tabora regions.
The programme is now being scaled up in the country.

6.0 Human Resource Development
This aspect of health reform includes: personnel development and their adequate
deployment with respect to number, qualification and skills and also with respect to
service needs at various levels of the health service. In order to interpret and implement



329
health and health related policies there should be capacity building at all levels in
planning, management and delivery of health services under a reformed environment. A
capacity building approach which is task-oriented, competitive and team-based should
be adopted in all levels of health care delivery.

7.0 Quality Assurance
There has been little effort to ensure that the health care provided is of good quality.
With general increase in public expectations for quality health care in all spheres
(particularly where the public is required to contribute towards the cost of the service)
there is a need to focus on quality assurance in health reform. It is the responsibility of
the Ministry of Health to ensure quality through proper supervisory, monitoring and
evaluation tools. Logistic support should be provided at various levels to enable them to
fulfill their supervisory roles and ensure that the quality of health services is maintained.
This could be achieved by the development of management support guidelines,
manuals and systems for various health care delivery levels.

8.0 Decentralization
Though many countries have embarked on decentralization, effective decentralization
including delegation of authority to hire and fire, and to manage financial resources is
still lacking. A number of factors that have rendered the decentralized health system
less effective are:
- The central level still retained most of the authority, some of which would be
necessary to facilitate implementation at the district level. Vertical programs are
planned at the central level with very little participation of the implementers.
- The concept of decentralization is not well understood and there was a tendency
of by-passing the relevant authorities in the handling of health management
issues and also in decision-making involving finances.
- Lack of clear decentralization Policy that would empower district authorities to
attain full administrative and managerial powers.
- Inadequate support to the district health management teams to enable them to
fulfill their supervisory roles and ensure that the quality of health services is
maintained by providing guidelines and manuals.
- Lack of comprehensive health sector plans that would be used by central
ministries to implement health activities at all levels and coordinate donor input.
- Inadequate health staffing and equipment for delivery of a minimum level of
acceptable health care.

9.0 Integration of services
Health reforms should aim at integrating various aspects of health delivery services
such as clinical services, preventive services with training in financial management and
supervision. The health services delivery system at all levels should be integrated and a
multi-sectoral approach should be adopted in the implementation of a community-based
health care system. There should also be a serious consideration for program
integration where feasible at all levels. Such integration should be reflected in the
decentralization policy.





330

10.0 Health Information System
This aspect of reform must include development and coordination of health information
systems that are useful for:
- Advocacy and policy development,
- documenting the burden and nature of illnesses,
- Monitoring quality and performance of health services.
- Estimating the cost of health service,
- Monitoring trends and changes on the overall health sector and
- Regular synthesis of health information useful in planning.

A comprehensive health management information system (HMIS) should be
implemented in the districts to support the planning and budgeting exercise.

11.0 Research
Most of the research on health including operational and bio-medical have not
depended on the demand of the national health system. Research in the reforms should
include essential national health research at all levels and the objectives should be:

- To identify operational health research priorities necessary to implement
successful health service delivery,

- To suggest the type of research needed to strengthen the management of the
health systems; and

- To select relevant and reasonable priority research projects and

- To identify researchers, institutions and donors who can implement them.

Operational research should especially address the aspects that deal with strategies,
approaches, access and utilization of services. They should also address technologies,
financial systems, quality assurance, case studies of functioning systems or strategies
and disease control.

















331


REFERENCES:

1. UNICEF. Strategic use of resources for child survival and development
in times of economic adjustment, 1988: Dar es Salaam.

2. World Bank. Financing health services in developing countries: an
agenda for reform, 1987 World Bank.

3. Ministry of Health, Tanzania. Proposals for Health Sector Reform,
December 1994, Dar es Salaam.

4. Better Health in Africa 1994, World Bank Report.





































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CHAPTER 25

BASIC STATISTICS FOR HEALTH CARE

Dalton Wamalwa and Jeremiah Banda

INTRODUCTION
Statistics is the science of collecting, organizing and interpreting numerical facts which
we refer to as data. Data are not just numbers, they are numbers within a context. The
statistical approach in health care pertains to defining and interpreting health
phenomena using numbers. This chapter presents some of the basic statistical
techniques which can be used to analyze and present statistics pertinent to primary
health care.
The purpose of the chapter stimulate students and other health workers to study more
statistical theory and methods in order to be equipped to collect reliable data and
accurately analyze such data.

OBJECTIVES
At the end of the chapter students should be able to:
Explain the role of statistics in Health Care
Discuss common and possible data sources on Health Care
Understand basic statistical parameters relevant to health related data including:
Rates and proportions
Measures of central tendency
Measures of dispersion
Tabular and graphic presentation of data

Sources of health care data

1. Censuses

For many countries a population census is conducted in every 10 years. Most
developing countries currently conduct their censuses on a complete enumeration
basis. This means that theoretically every household and person, in a country, is
enumerated. This results in having data for the whole country, at relatively small
administrative levels/domains. Through censuses, information on deaths and births is
usually collected. In addition, the census is a source of information on denominators
used in calculating rates to assess public health.

2. Vital registers

Registration of all deaths and births is required by law in most countries. A death
certificate is required for claiming insurance benefits of other administrative rights of the
deceased’s property. For countries which have complete or near complete vital
registration systems, vital statistics, including births and deaths can be generated on a
continuous basis. Unfortunately for most African countries the systems for registration



333
of births and deaths are not comprehensive. In general registration is better in the
urban settings compared to the rural areas.

Demographic Health Survey

At intervals of 5 years, countries carry out demographic health surveys. In these
surveys, a sample survey is carried out on a nationally representative number of people
(men and women aged 15 to 54 years) selected from about 400 sample points
(clusters) across the country. A sample comprises of a proportion of individuals or
units from the target population. Here a population is defined as a collection of
individuals or units from which a sample is selected. The results obtained from the
sample can be generalized to the population from which it is selected. Thus a
probability sample enables the researcher to make inferences from the sample results
to the population.

The national demographic and health survey obtains detailed information on fertility
levels, marriage, and sexual activity, breastfeeding practices, nutritional status of
women and children, childhood and maternal mortality, maternal and child health,
vaccination coverage, awareness and use of family planning methods, behaviour
related to HIV/AIDS. Some countries also include information on malaria and use of
mosquito nets, domestic violence and HIV testing of adults.

Some key outcomes of the demographic and health survey include:
Infant mortality rate: this is the probability of a child dying before they reach their first
birthday, expressed as number of deaths per 1000 live births.
Under-five mortality rate is the probability of a child dying before they reach their fifth
birthday.
Maternal mortality rate: this is the number of women who die during pregnancy or within
42 days of termination of the pregnancy irrespective of the duration or site of pregnancy
from any cause related to or aggravated by pregnancy or its management but not from
accidents or incidental causes. It is expressed as deaths per 100,000 live births.

4. Surveillance data and medical records

Public surveillance systems:
Surveillance is a process that is carried out on an ongoing basis to monitor changes in
disease frequency or to changes in the pattern of risk factors. A good surveillance
system will detect and possibly lead to prevention of a disease outbreak. The
information obtained from public health surveillance is analyzed and disseminated to
the health care implementers. For example the measles surveillance will report all
cases to the department of immunizations to institute mass vaccination and catch up
vaccination activities. In implementing a typical surveillance system doctors, medical
laboratories and other health care providers may be required, by law, to record and
report all cases of health conditions that may be specified as being notifiable.
Surveillance is mainly put in place for conditions that are infectious in origin.

Hospital, clinic records and other primary health care records: health statistics can also
be generated as byproducts of hospital, clinic and other administration systems. In



334
general information from the hospital records may not be representative of what
happens in the community. For instance during an outbreak of measles the children
who get admitted and die in the hospital may only represent the sickest subset.

Useful tools in public health statistics

1. Count: The absolute number of an event (e.g. infant’s deaths) occurring in a specified
area in a specified time period. For example, there were, 24,560 infant deaths recorded
in South Africa in 1996.
Absolute numbers are important for planning. In a specific country the number of
malaria infections may be used to plan the quantity of antimalarials required for a given
duration.

2. Ratio: a ratio is an expression of a relationship of any two quantities such as infant
deaths in a particular year to the number of live births in the same year.

3. Proportion: A proportion is a ratio in which the numerator is included in the
denominator. For example the number of children born HIV positive in a hospital, in a
particular year, over the total number of children born, in the same, that year.

Consider the proportion of patients infected with HIV in two countries (hypothetical).
Country A has a total population of 2,000,000 people of whom 200,000 are HIV
infected.

The proportion of people with HIV is:

200,000/2,000,000 = 10%
Country B has a population of 100,000,000 and has 1 million HIV infected people.
The proportion of HIV infected people in country B is:
1,000,000/100,000,000 = 1%.

Thus even though the absolute number of cases is higher in country B (1 million vs.
200,000), the proportion is higher in country A (10% vs. 1%).

4. Rate: A rate, measures a frequency of public health events among, say, children in
a specified time period. For example the infant mortality rate for Egypt, in 1999, was
29.4. This rate is the annual number of deaths of infants under one year of age per,
1,000 live births in the same year.

5. Incidence rate: Is the count of new (incident) cases divided by the amount of at-risk
experience from which the cases arose. The denominator is measured in units of
person-time.
Note: person-time is defined as the amount of follow-up time each individual contributes
e.g. 50 people followed for 1 year contribute the same number of person years as
100people followed for 6 months (i.e. 50 years)




335
6. Prevalence rates: Count of prevalent cases of a disease is the number of persons in
the population who are in the diseased state at a specified time. The proportion is
obtained by dividing the count of prevalent cases by the population size at the time.

Descriptive Statistics

Descriptive statistics are frequently used and can be used in different aspects of primary
health care. For instance, they are used when we want to describe how the data at
hand looks like and its common features. Descriptive statistics summarize data. The
summarized data, in most cases, facilitate easy and quick interpretation of the detailed
set of data. In health care, descriptive statistics can be and are used to manage,
monitor and evaluate health services and the persons working in such services

Descriptive statistics are, in general, categorized into two types: The first being
measures of central tendency, namely, the mean, median and mode. The second
category is measures of dispersion/variability, among them the range; inter quartile
range; variance and standard deviation.

1. Types of Data variables

There are 2 types of variable namely categorical variable and continuous variables.
Categorical variables include those which naturally occur in distinct groups e.g. sex
whereby one can only be either a male or female. Continuous data on the other hand
does not fit into natural groups and changes occur in gradual increments. Examples of
continuous variable are height and age.

2. Measures of Central Tendency

A measure of central tendency is a statistic which summarizes a given set of one
variable data. For example we may state that the average age of sick children in the
children’s ward at a particular hospital is 3 years and 5 months. This is a summary
figure derived from the total value of ages of children divided by the number of children.

It should, however, be pointed out that there a number ways of defining the measures
of central tendency. In this section we shall consider the following measures of central
tendency:
Mean
Median
Mode

Mean The arithmetic mean, which is the most commonly used measure of central
tendency, is simply the total of a set of values of a variable divided by the number of
observations. Thus, it is calculated by summing all the values in a set of data and then
dividing the total by the number of items involved. The data may come from the whole
population of interest, or a sample for example, recorded height in centimeters of a
sample of children (see table 1).





336

The formula for the population mean is

N
x x x x
N
+ ÷ ÷ ÷ ÷ + + +
=
3 2 1

(1)

Where
1
x
up to
N
x
are the observations for the whole population
( ) N
in our example
above of sick children in a particular hospital ward. The Greek letter
mu

( ) 
represents
the mean of the population.

The algebraic expression in (1) can also be presented as


=
N
x
N
i
i ¯
=1
(2)

¯
=
N
i
i
x
1
is the summation of all
i
x
values in the population from
1
x
to?
N
x


The formula for a sample mean is presented as follows:


x n
x x x x
n
+ ÷ ÷ ÷ ÷ + + +
=
3 2 1
(3)


Where:
x
is a sample arithmetic mean?

n
is the sample size

i
x
is the
th
i
observation of the random variable?
X



¯
=
n
i
i
x
1
is the summation of all
i
x
values in the sample from
1
x
to?
n
x

Data on the growth, in height in centimeters, for a hypothetical sample of 20 children
aged 1 to 20 years. The data depicts the extent of growth over the period. We shall use
this data to calculate the measures of central tendency and dispersion/variation.

Table. 1 Growth though childhood


Serial
number of
child
Height in
centimeters
( )
i
x



2
i
x

1 65 4,225
2 75 5,625



337
3 85 7,225
4 95 9,025
5 100 10,000
6 105 11,025
7 115 13,225
8 120 14,400
9 125 15,625
10 125 15,625
11 127 16,129
12 135 18,135
13 145 21,025
14 155 24,025
15 170 28,900
16 170 28,900
17 170 28,900
18 170 28,900
19 170 28,900
20 170 28,900


Average height in centimeters of the sample observations is

x
=
n
x
i ¯

=
20
170 100 95 85 75 65 + ÷ ÷ ÷ ÷ ÷ ÷ + + + + +

=
20
476 , 2
= 123.35
123 ~



Median: The median, which is another common measure of central tendency, is the
middle value, thus the physical centre, in an ordered sequence of data of a distribution
or data set. If the order set of number is odd, half of the observations will be smaller and
half will be larger than the middle value. The observations should be ranked from
lowest to highest value before determining the median. The median is less affected by
outliers in a set of data than the mean. Instead of using all the values to calculate the
measure of central tendency, it uses only the value in the middle of the distribution. It is,
therefore, often preferred as a measure of central tendency for skewed distributions.

To calculate the median, therefore, first the raw data should be put in an ordered array,
say in ascending order. In general the positioning point formula is:

2
1 + n
(4)




338
where
n
is the number of observations?


(a) If the number of observations is odd, the median is represented by the numerical
value corresponding to the positioning point, which is the
2
1 + n
ordered observation.
(b) If the number of observations is even, then the positioning point lies between the two
middle values. In this case the median is the arithmetic average of the numerical values
corresponding to the two middle observations. We shall illustrate the above two
situations in the examples that follow.

Example

From table 1, the median is calculated as follows:
We must recognize that the observations are ordered in ascending order and they are
even therefore we go by the formulation in (b) above. The two middle values are 125
and 127, taking an average of these two values means.

Median =
2
127 125 +
= 126
If the number of children we only 19 the median height should have been 25 by applying
formula (4) above in locating the median position.

Mode: The mode is the value in a set of data (distribution) which occurs most frequently.
It is easily obtained from an ordered array. The mode, unlike the mean is not affected
by presence of outliers a set of data.

It should however, be noted that the mode is used mostly for descriptive purposes
because it is, in practice, more variable from sample to sample compared to other
measures of central tendency.

From table 1 it is clear the most frequent value is 170, thus six observations in the
distribution.

Summary on measures of central tendency

The mean is the most commonly used measure of central tendency. All values in a
selected distribution are used in its calculation, in this way it is the most sensitive. As it
arithmetically based it can be used in other calculation as illustrated below under the
measurement of variation. As earlier stated, however, it is easily distorted by extreme
values. In addition, the mean can only be used on data of interval or ratio level of
measurement.

The median does not take into account the values of cases, therefore is not affected by
extreme values. It can be derived from ordinal, thus ranked data.




339
The mode is most useful categorical data, although it can be used on all levels of
measurement.

Measures of Dispersion

A single summary measure such as the mean is, under normal circumstances, sufficient
to describe or define a distribution, because it does not reflect the second important
characteristic of a distribution, namely, its variation or dispersion. In order, therefore, to
enhance our understanding of the pattern of the data there is also a need to measure its
dispersion. Why do we need to measure and understand dispersion of a distribution?

It gives additional information that enables one to assess the reliability of the measure
of central tendency. For example, if data are widely dispersed, the measure of central
tendency is less representative of the data as a whole than it would be if the data were
more closely clustered around the mean, for instance.

The measure of dispersion is the one of the first steps to take in an attempt, to resolve
peculiar problems associated with widely dispersed data.

It is common in empirical statistical research to compare dispersions of various
samples. This helps researcher to recognize and perhaps avoid distributions with the
greatest dispersion.

It is important to note that in the health care field it is important to know the variability in
children’s health.

1. Range: To calculate the range you subtract the smallest value, in a data set, from
the largest value. As example once again refer to table 1. The smallest and largest
value in the distribution is 65 and 170, respectively.

In this case the range will be:
170 – 65 = 105

The range is the simplest measure of dispersion.

2 Inter-quartile range: In order to deal with outliers in a distribution the use of an inter-
quartile range (
IQR
) is advisable. A quartile is derived by partitioning a data set into
quarters. The data are placed in an ascending order and then divided into four quarters.
The numbers at the upper boundaries of these quarters are called quartiles. Thus the
quartiles are the highest values in each of the four parts. The
IQR
measures,
approximately, how far from the median one has to go on either side before one
includes 50 per cent of the data set. The
IQR
is, therefore, the range for the middle fifty
per cent of the data.

The
IQR
is calculated by locating the upper value of the 1
st
quartile, and subtracting it
from the upper value of the 3
rd
quartile. Thus



340


IQR
=
1 3
Q Q ÷
(5)

= 170 – 100 = 70

It will be observed that the dispersion is somewhat reduced compared to the value of
the range. This is because its calculation, to the extent possible does not include
outliers such as 65.

One obvious shortcoming of the range and the IQR is that while they give an
indication about the spread of values of observations, they do not take into
consideration the concept of the level of deviation from the central tendency ( such as
the mean).
3. Variance: The variance is an average of squared deviations from the mean. As can
be seen from the formulas below, The sum of squared deviations/distances between the
mean and each item divided by the total number of elements in the population. In the
case of population variance, by squaring each deviation, we make every number
positive.

Population and sample variances: The Square of the Greek letter sigma
) (
2

usually
represents the population variance, while the sample variance is commonly represented
by
2
s
. The formulas for variances are as follows:

Population:
2

=
( )
2
N
x
i ¯
÷ 
=
2
2
 ÷
¯
N
x
i
(6)

Sample:
2
s
=
( )
2
1 ÷
÷
¯
n
x x
i
=
2 2
1 1 ÷
÷
÷
¯
n
x n
n
x
i
(7)
Where:

i
x
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
2
s
is the sample variance

In the calculations we use the data in table 1 which we assume to be sample data. In
our calculation we use the simplified formulation, thus:




341

2
s
=
2 2
1 1 ÷
÷
÷
¯
n
x n
n
x
i



Substituting the values

2
s
=
( )
19
22 . 215 , 15 20
19
404 , 358
÷


=
÷
19
404 , 358
19
40 . 304 , 304


= 18,864.37- 16,016.02
= 2,848. 35

=
~
2,848

4. Standard deviations (SD) The standard deviation of the population and sample
variances is the square root of their variances.

i) Population
= 
( )
N
x
i ¯
÷
2

=
2
2
 ÷
¯
N
x
i
(8)

ii) Sample s =
( )
2
1 ÷
÷
¯
n
x x
i
=
1 1
2 2
÷
÷
÷
¯
n
x n
n
x
i
(9)

SD
35 . 848 , 2 = s


= 53.37


~
53

The standard deviation is the most commonly used measure of dispersion in describing
data. It is the measure of the variation in the data that assesses how much each value
deviates from the mean.

Use of Mean and Median (distribution of data)

Most naturally occurring distributions are normal. In such distributions, the mean is very
close (or equal) to the median. However some distributions are skewed (either right
skewed in which case the mean is far greater than the median, or left skewed in which
case the mean is significantly less than the mean. The median is relatively unaffected
by extremes figures (in statistics the mean is considered to be robust).



342
The best representation of normal data uses the mean and standard deviations while
skewed data is best represented using the median and inter quartile range.

Tabular and graphic representation of data

When data are collected, there is need to present them in an orderly manner for them to
be understood, especially, when you have a large array of data. Data can grouped into
classes or frequency distributions; presented in a tabular form or charts and as
discussed above calculated and presented as summary statistics. Tables and graphs
summarize and present data in a way that is easy to understand and assimilate.
Displaying data is usually an important part of analyzing the data. According to Scott
and Mazhindu, (2005) “it allows you to establish how data are distributed, to see
unusual cases and generally get a feel for the data.” Tables present information in a text
form while graphs help display patterns although some details are lost.

We briefly discuss and present a table; line graph; bar chart; multiple bar chart and pie
charts derived from the small data set given in table 2.

It should be pointed out that many more graphs and charts are used by statisticians and
other data users to display data.

1. Tables: The purpose of tables is to summarize and thereby facilitate the comparison
of data.

Listed below are the general features of which a good table should have:

A title which is a brief explanation of the contents of the table including the units of
measurement;
A column title or caption showing the classification with respect to columns
A row title or stub to showing classification with respect to rows.
A source note at the bottom of the table indicating the source of data.

Table 2. Age, sex distribution of battered babies at Kenyatta Hospital,


Age
Sex
Male Female
10-11months 11 7
12-24
months
1 2
2-5yrs 2 4
6-10 yrs 2 1
Total 16 14

Source: Nduati and Muita, Nairobi, 1989





343
Questions:
What proportion of the all children are males?
What is proportion of female sin the age group 6-10 years?
From this table do you think male infants are more likely to be battered?

2. Line graph: To draw a line graph we must have values which are pertinent to the
y
-
axis (vertical axis) and
x
- axis (horizontal axis). The position of any point on the graph
is located by the
y
and
x
coordinates. With respect to figure 1 examining the female
line graph the number of battered children in the age range 10-11 months is 7, as we
move along the
x
-axis the number reduces to 2 battered children in the age range 12-
24 months. Then we move upward on the scale until the number 4 for those battered
aged 2-5 years and then declines to 1 for those aged 6-10 years. A straight line is then
drawn through the located points.














Figure 1. Number of battered children at Kenyatta Hospital by age and sex (1989)
0
2
4
6
8
10
12
10-11mons 12-24 mons 2-5yrs 6-10 yrs
Age
N
u
m
b
e
r
Male
Female



344




Bar Chart: In a simple bar chart the bars are of equal thickness but the length is varied
in proportion to the values represented. This chart is given in figure 2. below.



































4. Multiple Bar Charts In figure 3 we see a graph where two sets of data have been
graphed using the same values (age ranges) in the horizontal axis. This graph, for
example, facilitates easy graphic comparison of number of battered boy and girls by age
group.



0
2
4
6
8
10
12
10-11mons 12-24 mons 2-5yrs 6-10 yrs
N
u
m
b
e
r
age
Figure 2. Battered male children at Kenyatta Hospital
by age
Series1



345


5. Pie chart:
A pie chart displays a count of observations in a nominal group as a proportion (per
cent age) of the total number of counts. The total data is represented as a circle which
is divided into segments whose sizes represent the frequency of each group. For
example figures 4 and 5 shows the proportions of battered boys and girls, respectively,
under different age groups. Pie charts are ideal for simple data. If you include many
subgroups or categories it may be difficult to read.


Figure 3. Battered children at kenyatta Hospital by sex and age (1989)
0
2
4
6
8
10
12
10-11mons 12-24 mons 2-5yrs 6-10 yrs
Age of children
N
u
m
b
e
r
Sex Male
Sex Female



346





Spend some time analyzing the graphs and charts and come up with an objective
story!
Figure 4: Male battered children at kenyatta Hospital by age
10-11mons
68%
12-24 mons
6%
2-5yrs
13%
6-10 yrs
13%
10-11mons
12-24 mons
2-5yrs
6-10 yrs
Figure 5.Female battered children at Kenyatta Hospital by age (1989)
10-11mons
50%
12-24 mons
14%
2-5yrs
29%
6-10 yrs
7%
10-11mons
12-24 mons
2-5yrs
6-10 yrs



347
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