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Answers to the Five Questions Posed to the Committee

THE SICK CHILD INITIATIVE IN THE CONTEXT OF HEALTH CARE AND WELFARE

The major purpose of integrating the primary health care worker's management of childhood illnesses is to improve the efficacy and efficiency of management of childhood diseases, including malnutrition and other presenting complaints. This is, of course, done within a larger context of health care, including preventive health care and the curative care obtained in a manner other than face-to-face contact with the primary health care worker. This is recognized in the SCI in its referral of some children in need of curative care to more specialized levels and by incorporation of some preventive measures into the algorithms for the primary health care worker.

There is yet a larger setting to be considered in the delivery of primary health care. In many countries, the health sector, and in particular the primary health care component of that sector, is the entry point for the poor into the larger societal support structure. The SCI algorithms thus must establish and incorporate appropriate links to other health and social services programs. At present there is little discussion of this larger context in the SCI documents reviewed.

Two such links require urgent consideration: the referral of very sick and severely malnourished children who probably need hospitalization, and the referral of others to curative and preventive interventions that might be more



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Consideration of the Nutrition Components of the Sick Child Initiative 3 ◆ ◆ ◆ ◆ ◆ Answers to the Five Questions Posed to the Committee THE SICK CHILD INITIATIVE IN THE CONTEXT OF HEALTH CARE AND WELFARE The major purpose of integrating the primary health care worker's management of childhood illnesses is to improve the efficacy and efficiency of management of childhood diseases, including malnutrition and other presenting complaints. This is, of course, done within a larger context of health care, including preventive health care and the curative care obtained in a manner other than face-to-face contact with the primary health care worker. This is recognized in the SCI in its referral of some children in need of curative care to more specialized levels and by incorporation of some preventive measures into the algorithms for the primary health care worker. There is yet a larger setting to be considered in the delivery of primary health care. In many countries, the health sector, and in particular the primary health care component of that sector, is the entry point for the poor into the larger societal support structure. The SCI algorithms thus must establish and incorporate appropriate links to other health and social services programs. At present there is little discussion of this larger context in the SCI documents reviewed. Two such links require urgent consideration: the referral of very sick and severely malnourished children who probably need hospitalization, and the referral of others to curative and preventive interventions that might be more

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Consideration of the Nutrition Components of the Sick Child Initiative efficiently performed by individuals other than the health worker using the present SCI algorithms. The diagnosis and management of sick or malnourished children by the primary health care worker require attention to the following components: The ability of the caretaker to identify the disease; to treat it correctly, at home when appropriate; or to seek appropriate assistance in circumstances where the SCI considers it is best provided by the local health worker. The ability of the health worker to diagnose the disease, to negotiate treatment with the child's caretaker, to provide the resources for treatment when appropriate, and to follow up to assure satisfactory evolution of the problem. The ability of the caretaker to understand and to implement the prescription, and to seek further help when appropriate. The WHO documents submitted to the committee dealt with the second of these three components, and thus only the resources directly provided by the health worker—such as counseling and medicines—are described here. WHO recognizes that the other two components are also essential and is in the process of addressing them, but it has not yet advanced far in their documentation. The organization of referrals to other programs and the competence of these programs to deal with their responsibilities effectively is a challenge that must be met in the future for the SCI to achieve maximum effectiveness. The impact of the initiative will be greatly enhanced if the paths for integrating SCI activities with any other resources for the treatment and prevention of illness and disease, including malnutrition, are clearly identified when the algorithms are adapted for each location. QUESTIONS 1 AND 2: Make recommendations on the practicality of the nutrition components of the (SCI) algorithm, and whether the nutrition components of the algorithm should or should not be modified, and if to be modified, how? The committee's responses to these two charges have been combined. Because the nutrition component of the SCI is still evolving, the committee felt that broader considerations were more relevant to this report than specific recommendations. The Diagnosis of Severe Malnutrition and Severe Anemia The diagnostic approach to assess these conditions is similar to that used for other illnesses addressed by the SCI. Most of the clinical symptoms are

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Consideration of the Nutrition Components of the Sick Child Initiative qualitatively obvious and can be standardized. The screening tools are innovative, and the tools are being tested, with very promising results. The next step will be to ascertain the relative quality of the screening tools in different environments, using data from more health workers in each location to develop Receiver Operating Characteristics (ROC) curves. In Appendix B, the committee provides several suggestions for further development of diagnostic screens and indicators that predict benefit. Treatment of Severe Malnutrition Severe malnutrition is to be handled by the primary health worker through an urgent referral of the child to a hospital. The practicality of this strategy depends on the accessibility of effective hospital care for severe malnutrition. This includes blood transfusion for life-threatening anemia and intensive feeding of children with marasmus and kwashiorkor, including gastric intubation and intravenous electrolyte stabilization and antibiotic treatment when necessary. Intensive feeding is always a critical component of the management of marasmus and kwashiorkor, both initially and as treatment proceeds. Few hospitals in developing countries have the resources to do this, unless assisted by family members. Thus, successful intensive feeding may require a different concept of hospital care and needs to be addressed if referral is to be a meaningful intervention in the SCI. Diagnosis of Moderate Malnutrition or Anemia The diagnosis of “moderate malnutrition” is based on weight-for-age. The validity of this screen is currently being tested against weight-for-height as the presumed “true” outcome of moderate malnutrition. Weight-for-height, however, is not a good measure of moderate malnutrition in many populations (Victora, 1992). Height-for-age may be a better “gold standard” for validating the weight-for-age screen, especially over the period when active stunting exists (up to about 2 years of age) and in areas where weight-for-height is relatively unaffected by moderate malnutrition despite widespread stunting (that is, in regions other than South and Southeast Asia) (Victora, 1992). The appropriate outcome for validation is likely to depend on epidemiological information collected during the in-country adaptation phase. After 18–22 months of age, low weight- or height-for-age are increasingly likely to reflect past undernutrition rather than current feeding. Consideration might be given to developing different thresholds for low weight- or height-for-age at different ages. Thus, validation of the anthropometric screen to define and measure moderate malnutrition is an area that requires further development (Appendix B).

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Consideration of the Nutrition Components of the Sick Child Initiative The diagnosis of moderate anemia in the SCI depends on assessment of pallor, but the use of this indicator remains to be validated to the same degree that it has been in the detection of severe anemia. This is important given the high prevalence of moderate anemia and its well-established detrimental effects on human function. Treatment of Moderate Malnutrition The treatment of moderate malnutrition depends on an assessment of feeding practices and the giving of feeding advice, both of which are time-consuming. If moderate malnutrition is prevalent in the area where the clinic is located, both activities might be more efficiently and effectively performed for groups of children and their caretakers through participatory assessment strategies and “teaching by doing ” approaches. The IMCI might consider how to develop or work with existing group interventions where this seems to be a more practical strategy. The face-to-face meeting of the primary health care worker with the mother or caretaker must be used to motivate the mother or caretaker to participate in these group interventions. The committee believes that these interventions are as important for the SCI as the development of appropriate referral institutions for severely ill children, and may well be more cost-effective. In Appendix B, a number of suggestions are provided for the assessment of feeding practices and feeding recommendations. In general, the committee felt that some aspects of the assessment of breastfeeding and other feeding practices were unnecessarily complicated, while the development of locally appropriate feeding recommendations will require substantially more effort. Nutritional Management of Sick Children Who Are Not Malnourished The basic SCI approach of fostering and encouraging the continued feeding of the sick child, with special emphasis on continued breastfeeding during illness, is now recognized as correct and appropriate (Brown, 1994). Prevention of Malnutrition within the Management of the Sick Child The face-to-face meeting between the caretaker of the sick child and the primary health worker provides an opportunity to improve present and future feeding practices, with the goal of preventing malnutrition. This is especially important during breastfeeding and weaning. Again, in many situations this may

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Consideration of the Nutrition Components of the Sick Child Initiative be best accomplished through referral to mothers' groups, such as those mentioned above. QUESTION 3: What additional information or data are required to improve the performance of the integrated management of childhood illness algorithm's nutritional effectiveness? Validating the Diagnosis The approach of the SCI to validating diagnoses for severe malnutrition and severe anemia is logical, because it separates validating the diagnosis of severe malnutrition from that of less severe malnutrition in the same way as they are separated in their immediate management. Further data collection and the use of methodologies to analyze these data are pending. This is an area of research in which the SCI has now taken the lead. The validation of diagnoses of moderate malnutrition is more difficult because clear-cut outcomes of functional significance, such as rapid death, are less easily used for validation. Death in the longer-term could be studied but requires more time and data collection, as well as different analytic strategies. The use of shorter-term proxies to validate the diagnosis of moderate malnutrition is a problem that requires more scientific attention, as discussed in the answer to Questions 1 and 2 and Appendix B. Treatment Treatment of malnutrition requires the collection of information about feeding practices, which is time-consuming and cannot be done well under the present time constraints of the SCI examinations. Treatment of moderate malnutrition and the prevention of malnutrition in populations where it is prevalent depends on significant behavior modification. Achieving such modifications is also time-consuming, and as currently practiced it may not be effective on a one-to-one basis in the context of the management of the sick child. Both of these problems could be resolved by permitting much more time for each encounter in the SCI. Time constraints, however, are today's reality in the management of sick children. Whether or not these constraints can be overcome is thought to depend on personnel resources. More research might reveal other ways to deal with these tasks than by increasing the one-to-one encounter time. Other resources for establishing community interaction should be identified. One way that is already done in many countries is by the referral of mothers to groups for learning about nutrition and other mother-care issues—for example,

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Consideration of the Nutrition Components of the Sick Child Initiative where growth monitoring and promotion programs are in place. Whether this approach might be usefully incorporated into the SCI requires more research. The effective treatment of malnutrition also depends on the development of local feeding recommendations. This, in turn, requires information on the type and composition of foods used and appropriate for this purpose, and on whether these foods can maintain adequate nutritional status of infants and children. More effort will be needed in this area. QUESTION 4: How can nutritional components be monitored during field testing or introductions? The incorporation of monitoring into the SCI is important, and it is part of the philosophy of the CDR section of WHO. The development of appropriate monitoring of the nutrition components is pending, because further definition of the nutrition goals of the SCI and the means to attain them are required. The goals must be further defined to identify the intermediary and outcome variables that will be the best measures of whether the intervention has attained its goals. With this information it will be possible to define how the nutrition components can be monitored during field testing, as well as in ongoing programs. There is much work to be done in this area. QUESTION 5: What should the role be for those with experience and expertise in nutrition as field testing or introduction evolves? Nutrition expertise at this juncture in the development of the nutrition component of the SCI, whether at WHO or elsewhere, is needed to define the nutritional goals of the SCI and the means to attain them, validate the diagnostic screens, evaluate the nutrition assessment algorithms, develop and evaluate feeding recommendations (especially for complementary feeding), evaluate the effectiveness of the SCI advice in changing feeding behavior, design monitoring to ascertain whether the goals have been met, and to deal with the inevitable changes in knowledge as experience develops. The task of mobilizing this expertise should not reside solely within CDR at WHO, or even solely within WHO. The SCI has a broad-based constituency that involves many organizations, with the leadership at WHO. In its management of the Diarrheal Disease Prevention Program, CDR has been a paragon of how to mobilize the research community to advance the implementation of programs that are effective in improving health. One may expect CDR to build on that experience. Equally important is that other agencies concerned with effective action in nutrition build on that experience in furthering the SCI. They should

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Consideration of the Nutrition Components of the Sick Child Initiative mobilize scientists with the appropriate expertise and experience to focus attention on the many issues in the SCI that require further research and testing.

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