4

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Summary and Conclusions

  • Because an estimated 57 percent of infant and child deaths in developing countries are caused by the synergistic impact of malnutrition on common illnesses of infancy and childhood, the concept of including the assessment and management of nutrition in the integrated management of childhood illness is extremely important, and it is the basis of the international effort called the Sick Child Initiative (SCI). The World Health Organization (WHO) deserves the highest praise for its efforts to put this concept into practice through its Integrated Management of Childhood Illness (IMCI) activities. Major advances have been made in developing and testing the nutrition components of the SCI, but many problems remain unresolved.

  • The use of the clinical encounter as a vehicle for identifying children with malnutrition and initiating a process of management to improve their nutritional status is a major accomplishment of the SCI. It is long overdue. Nevertheless, the present format of problem identification and counseling presents many logistic difficulties and does not provide mechanisms for adequate follow-up. These two issues will have to be resolved if the goals of the SCI are to be achieved. Without concerted attention to these problems, there is a significant danger of a backlash effect, in which the frustrations of health workers will cause programs to eliminate the nutrition components from the algorithms. This would be tragic because the strong role of malnutrition in childhood mortality and impaired development is now incontrovertible, and the IMCI presents an important opportunity to address this global problem.

  • The CIN perceived that certain aspects of the nutrition components of the SCI have been more thoroughly developed than others, and that some have been tested empirically—especially those related to diarrhea —while others would benefit from the same rigorous field testing that has been conducted on assessment



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OCR for page 17
Consideration of the Nutrition Components of the Sick Child Initiative 4 ◆ ◆ ◆ ◆ ◆ Summary and Conclusions Because an estimated 57 percent of infant and child deaths in developing countries are caused by the synergistic impact of malnutrition on common illnesses of infancy and childhood, the concept of including the assessment and management of nutrition in the integrated management of childhood illness is extremely important, and it is the basis of the international effort called the Sick Child Initiative (SCI). The World Health Organization (WHO) deserves the highest praise for its efforts to put this concept into practice through its Integrated Management of Childhood Illness (IMCI) activities. Major advances have been made in developing and testing the nutrition components of the SCI, but many problems remain unresolved. The use of the clinical encounter as a vehicle for identifying children with malnutrition and initiating a process of management to improve their nutritional status is a major accomplishment of the SCI. It is long overdue. Nevertheless, the present format of problem identification and counseling presents many logistic difficulties and does not provide mechanisms for adequate follow-up. These two issues will have to be resolved if the goals of the SCI are to be achieved. Without concerted attention to these problems, there is a significant danger of a backlash effect, in which the frustrations of health workers will cause programs to eliminate the nutrition components from the algorithms. This would be tragic because the strong role of malnutrition in childhood mortality and impaired development is now incontrovertible, and the IMCI presents an important opportunity to address this global problem. The CIN perceived that certain aspects of the nutrition components of the SCI have been more thoroughly developed than others, and that some have been tested empirically—especially those related to diarrhea —while others would benefit from the same rigorous field testing that has been conducted on assessment

OCR for page 17
Consideration of the Nutrition Components of the Sick Child Initiative and treatment of diarrheal disease. The recommendations for nutrition assessment of very malnourished children are strongly developed. In contrast, the diagnosis and treatment of less malnourished children —who will be a large proportion of those to be managed—is less well thought out. The CIN, however, strongly supports the continued inclusion of, and attention to, moderately malnourished children in the SCI. Another concern is the role of prevention of malnutrition in the SCI. The biggest concern is the appropriateness and feasibility of assessing child feeding practices and giving feeding advice to the mother or caretaker. Some components of the SCI feeding assessment and recommendations reviewed by the committee may be impractical and not feasible. The international community concerned with the SCI must give attention to the development of methods for identifying, facilitating, or establishing complementary community support systems and other means of supporting and achieving changes in child feeding practices. The committee recommends that these and related concerns be carefully addressed in the next phases of development of the SCI. The nutrition community—including WHO and USAID—should be mobilized to become more involved in the development and validation of diagnostic tools, the feeding recommendations, and the effectiveness of the SCI, using a model similar to that followed so successfully in WHO's CDR (WHO, 1995). Experience in the diarrheal disease program has shown that the development of the nutrition components of the SCI will be a multiyear endeavor. The unresolved issues require a research agenda that would benefit from collaboration with one or more organizations that are capable of mobilizing scientists and the expertise required. In conclusion, the committee recommends to USAID that it support endeavors to focus scientific expertise on resolving the outstanding questions concerning the nutrition components of the SCI. The more rapidly these are resolved, the more rapidly the SCI can be implemented, and the more effective it will be in reducing childhood malnutrition and its synergistic impact on child illness in developing countries.