Consideration of the Nutrition Components of the Sick Child Initiative (1995)

The Sick Child Initiative (SCI) attempts to integrate separate case management systems into one entity. It provides an approach for the management of diarrhea, respiratory infection, malaria, measles, and malnutrition in one integrated system. A crucial goal of SCI is to identify the minimum essential elements for the diagnosis and treatment of each of these five disease components. The algorithms are intended for use in first-level health facilities that have minimal equipment, so that diagnosis depends primarily on the medical history and physical examination of the child by the health worker. The nutritional assessment uses simple techniques, and it is assumed to be possible with the level of technical expertise that reflects the current skills of clinical health workers when they are provided with some additional training.

The nutrition algorithm is divided into three broad components: assessment, classification, and treatment (see Appendix D for the algorithm). The nutrition assessment component, “Classify Nutritional Status,” relies on relatively simple measurements for the identification of malnutrition and anemia. It assumes that a scale is available for weighing the child, but not a lengthboard to measure height or length or equipment for measuring hemoglobin or hematocrit. The identification of malnutrition and anemia is based on the presence or absence of following: visible severe wasting, pallor, clouding of the cornea, foamy patches on the whites of the eyes, or edema of both feet. The child is also weighed, and weight-for-age is classified as “low” or “not low. ” Based on these symptoms, the child (age 2 months to 5 years) is classified in one of the three groups described in the following sections.

This classification is given if a child has any one of the following symptoms: visible severe wasting, severe pallor, clouding of the cornea, or edema of both feet. Such children are given vitamin A and an urgent referral to hospital.

This classification is based on the presence of one of the following: low weight-for-age, foamy patches on the white of the eye, or pallor. Children in this category will have their feeding assessed, using one set of questions for infants age 1 week to 2 months, and another set for those 2 months to 5 years. For the younger groups, questions are asked about whether there is difficulty in feeding and the frequency of breastfeeding and consumption of other foods and drinks. Breastfeeding is further assessed by observing the attachment and suckling effectiveness of infants during a 4-minute period for infants who have not fed for at least an hour. For the older infants, the mother is asked questions about breastfeeding frequency and diurnal patterns; type, frequency, amounts, and providers of other foods and feeding techniques; and any changes in feeding as a result of illness. The mother's answers are compared with a set of “Feeding Recommendations during Sickness and Health” that are intended for all children up to 5 years, and referred to as the “Food Box.” The “Food Box” provides basic information on how and what the child should be fed from the ages of 0–4 months, 4–6 months, 6–12 months, 12 months–2 years, and 2 years and older. The mother then is counseled as appropriate using the “Counsel the Mother” chart.

Administration of vitamin A and counseling on the use of foods rich in vitamin A are recommended for children with foamy patches on the eye. For children with pallor, medicinal iron is given for 14 days; after this period the mother is asked to return to obtain sufficient iron to last up to 2 months. (If pallor still exists at 2 months, the child is referred for assessment.) An oral antimalarial drug is advised in high malaria areas, and mebendazole, a broad-spectrum antiparasitic agent, is recommended for children older than 2 years who have not had a dose in the prior 6 months. For children with low weight-for-age or pallor, the mother is asked to return with her child in 14 days. At that time the child is reweighed, weight gain is calculated, and feeding is reassessed. If weight gain has been inadequate or the child has lost weight, or if the child has a feeding problem, the mother is counseled about problems found by the health worker, who again refers to the “Food Box” and the “Counsel the Mother” charts. The mother is asked again to return with her child in 14 days or is referred. If weight gain is good, the mother is encouraged to continue.

For cases of sick children who present with none of the key indicators, if the child is under 2 years of age, feeding is still assessed and mothers are advised about infant and child feeding based on information contained in the Food Box (see Appendix D). If the child is over 2 years of age, and has no signs of malnutrition or anemia, no feeding assessment or advice is proposed. Thus, the nutrition algorithms also incorporate the concept of prevention of malnutrition by providing feeding recommendations to sick, but well-nourished, children.

The complementary foods to be provided for those under 2 years of age are intended to be derived for each location by consultants working with national and/or local staff during a forthcoming, in-country adaptation phase of the algorithms. This strategy recognizes that the composition of weaning foods often varies by country, and even within countries, and that for the health worker's advice on infant feeding to be relevant to the caretaker, examples of nutritionally appropriate, locally available foods must be developed. The “Counsel the Mother” chart also provides guidance to health workers on the most common feeding problems and potentially feasible, locally adapted, solutions.

Because application of the entire set of SCI algorithms is supposed to take less than 10 minutes for each mother/child pair, the “Assessment of The Child's Feeding” and “Counseling the Mother About Feeding Problems” components must be done quite rapidly. Newly trained health workers in Ethiopia, however, took on average of 15 to 20 minutes to perform the medical consultations in a pilot study, and about half of this time was taken by the nutrition counseling (M. S. Lung'aho, WellStart International, Washington, D.C., personal communication, 1995).