Consideration of the Nutrition Components of the Sick Child Initiative

Committee on International Nutrition

Food and Nutrition Board

Board on International Health

INSTITUTE OF MEDICINE

Lindsay H. Allen and Christopher P. Howson, Editors

NATIONAL ACADEMY PRESS
Washington, D.C. 1995



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Consideration of the Nutrition Components of the Sick Child Initiative Consideration of the Nutrition Components of the Sick Child Initiative Committee on International Nutrition Food and Nutrition Board Board on International Health INSTITUTE OF MEDICINE Lindsay H. Allen and Christopher P. Howson, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1995

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Consideration of the Nutrition Components of the Sick Child Initiative National Academy Press 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the U.S. Agency for International Development under the terms of Grant No. HRN-5110-G-00-3043-00. The opinions expressed herein do not necessarily reflect those of the U.S. Agency for International Development. Additional copies of this report are available in limited quantities from: Food and Nutrition Board Institute of Medicine 2101 Constitution Avenue, N.W. Washington, DC 20418 Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Consideration of the Nutrition Components of the Sick Child Initiative COMMITTEE ON INTERNATIONAL NUTRITION LINDSAY H. ALLEN (Chair), Department of Nutrition, University of California, Davis, California KENNETH H. BROWN, Department of Nutrition, University of California, Davis, California JEAN-PIERRE HABICHT, Division of Nutritional Sciences, Cornell University, Ithaca, New York EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, Washington, D.C. JOANNE LESLIE, University of California-Los Angeles School of Public Health, and Pacific Institute for Women's Health, Los Angeles, California GILBERT A. LEVEILLE, Research and Technical Services, Nabisco Food Group, East Hanover, New Jersey Liaison to the Committee ALFRED SOMMER (Food and Nutrition Board),* School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland Staff CHRISTOPHER P. HOWSON, Project Director SUSAN M. KNASIAK, Research Assistant JAMAINE L. TINKER, Financial Associate * Member, Institute of Medicine

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Consideration of the Nutrition Components of the Sick Child Initiative FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, University of Illinois, Urbana, Illinois PERRY L. ADKISSON,† Department of Entomology, Texas A&M University, College Station, Texas LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis, California DENNIS M. BIER, Children's Nutrition Research Center, Houston, Texas FERGUS M. CLYDESDALE, Department of Food Science and Nutrition, University of Massachusetts, Amherst, Massachusetts MICHAEL P. DOYLE, Department of Food Science and Technology, University of Georgia, Griffin, Georgia JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Tufts University Schools of Medicine and Nutrition, Boston, Massachusetts SCOTT M. GRUNDY, University of Texas Southwestern Medical Center, Dallas, Texas K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver, Colorado JANET C. KING,* U.S. Department of Agriculture Western Human Nutrition Research Center, Presidio of San Francisco, California SANFORD A. MILLER, Graduate School of Biomedical Sciences, University of Texas Health Science Center, San Antonio, Texas ALFRED SOMMER,* School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland STEVE L. TAYLOR (Ex Officio), Department of Food Sciences and Technology, University of Nebraska, Lincoln, Nebraska VERNON R. YOUNG,† School of Science, Massachusetts Institute of Technology, Cambridge, Massachusetts Staff ALLISON A. YATES, Director BERNADETTE M. MARRIOTT, Associate Director GAIL A. SPEARS, Administrative Assistant JAMAINE L. TINKER, Financial Associate * Member, Institute of Medicine † Member, National Academy of Sciences

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Consideration of the Nutrition Components of the Sick Child Initiative BOARD ON INTERNATIONAL HEALTH BARRY R. BLOOM (Cochair),* Howard Hughes Medical Institute, Albert Einstein College of Medicine, Hastings-on-Hudson, New York HARVEY V. FINEBERG (Cochair),* Harvard School of Public Health, Boston, Massachusetts JOHN H. BRYANT,* Moscow, Vermont JACQUELINE CAMPBELL, The Johns Hopkins University School of Nursing, Baltimore, Maryland RICHARD G. A. FEACHEM, London School of Hygiene and Tropical Medicine, University of London, England JULIO FRENK,* Fundación Mexicana para la Salud, San Jerónimo Líce, Mexico DEAN JAMISON,* University of California, Los Angeles, California EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, Washington, D.C. ARTHUR KLEINMAN,* Harvard Medical School, Boston, Massachusetts WILLIAM E. PAUL, National Institute of Allergy and Infectious Diseases and Office of AIDS Research, National Institutes of Health, Rockville, Maryland PATRICIA ROSENFIELD, The Carnegie Corporation of New York, New York, New York THOMAS J. RYAN, Boston University School of Medicine and Boston University Medical Center, Boston, Massachusetts SUSAN C. M. SCRIMSHAW,* University of Illinois School of Public Health, Chicago, Illinois JUNE E. OSBORN (Institute of Medicine Liaison),* The University of Michigan School of Public Health, Ann Arbor, Michigan WILLIAM H. FOEGE (Ex Officio),* Carter Center, Emory University, Atlanta, Georgia DAVID P. RALL, (Institute of Medicine Foreign Secretary),* National Institute of Environmental Health Sciences, Washington, D.C. Staff CHRISTOPHER P. HOWSON, Director KIMBERLY A. BREWER, Research Assistant DELORES H. SUTTON, Project Assistant JAMAINE L. TINKER, Financial Associate * Member, Institute of Medicine

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Consideration of the Nutrition Components of the Sick Child Initiative ◆ ◆ ◆ ◆ ◆ Preface Over the past 2 years there has been a growing awareness of the potential value for the U.S. Agency for International Development (USAID) to have a standing capability in the Institute of Medicine (IOM) for a more flexible, less costly response to agency needs for advice in the areas of nutrition, food, and health science policy. With support from USAID, the IOM responded in October 1993 by establishing the Committee on International Nutrition (CIN) under the aegis of the Food and Nutrition Board (FNB) and the Board on International Health (BIH). The CIN's mandate is to answer questions of interest and concern, evaluate current nutrition activities undertaken by the agency, and make recommendations for future activities based on this review. Topics are chosen through systematic consultation with the Office of Nutrition in USAID's Bureau for Research and Development. Representing the areas of human nutrition, maternal and child health, epidemiology, economics, and program design and evaluation, the committee's six members will convene three times to produce brief reports that review specific programs, research projects, or project designs. With an initial project life of 18 months, the CIN is designed to be flexible (that is, capable of responding to specific nutrition concerns that arise abruptly) and to provide quick report turnaround. This report is the result of the third meeting of the CIN, which was held on 19–20 January 1995. The purpose was to comment on the nutrition components of the World Health Organization's (WHO) initiative to integrate the management of childhood illness. This is often called the “Sick Child Initiative” (SCI). The report was requested by USAID's Office of Health and Nutrition, a primary funding source for the initiative, on 8 December 1994. The CIN wishes

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Consideration of the Nutrition Components of the Sick Child Initiative to emphasize that the report was not requested by WHO and that WHO was not represented at the CIN meeting. Also, in spite of a major effort on WHO's part to share its latest documents with the CIN, the committee is aware that it did not have access to much of the relevant documentation. This report, then, does not represent a thorough scientific review of WHO's contribution to the nutrition components of the SCI. Rather, it should be viewed as a series of general observations concerning the draft documents available to the committee that are intended to expand the process of thinking about how to combine nutrition assessment, treatment, and advice into the integrated management of sick children and the maintenance of adequate nutrition and health. CHARGE TO THE COMMITTEE The initial charge to the committee by USAID was as follows: Drawing on the scientific and technical knowledge of individual members, background information and other pertinent data, the Committee is requested to make recommendations as to: (1) practicality of the nutrition components of the (SCI) algorithm; (2) whether the nutrition components of the algorithm should or should not be modified, and if to be modified, how; and (3) the additional information or data required to improve the performance of the integrated management of childhood illness algorithm's nutritional effectiveness. Further background information and details on USAID's initial request to the CIN can be found in the memorandum to the committee from Samuel G. Kahn, USAID Office of Health and Nutrition (Appendix A). In addition to this initial request, on the first day of the meeting Caryn Miller of the USAID Office of Health and Nutrition requested that two additional questions be considered: (4) how can nutritional components be monitored during field testing or introductions, and (5) what should the role be for those with experience and expertise in nutrition as field testing or introduction evolves? During the 2-day meeting, the CIN reviewed background information supplied by USAID. The documents that will be referred to most frequently are: “Assess and Classify the Sick Child Age 2 Months up to 5 Years ”; “Advise the Mother”; “Treat the Child”; “Management of Childhood Illness,” February 1995 drafts; “An Integrated Approach to Management of Childhood Illness: Development and Research Activities,” 4 March 1994 draft; and “Integrated Management of Childhood Illness: Research Priorities,” January 1995 draft. These documents were all generated by WHO. Additional documents available to the committee are listed in Appendix B.

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Consideration of the Nutrition Components of the Sick Child Initiative ORGANIZATION OF THE REPORT The report contains four chapters and four appendixes. Chapter 1 provides background information on the SCI, the charge to the committee, and the scope of the committee's deliberations. Chapter 2 describes the nutrition algorithms in the SCI. In Chapter 3, the committee presents its responses to the five questions posed by USAID. Although the committee was not asked specifically to consider SCI in the larger context of health care and child welfare, it believes strongly that integration of SCI activities with other local resources for the treatment and prevention of illness and disease, including malnutrition, will be required for SCI to be most effective. Thus, the committee ends Chapter 3 with suggestions toward this end. The committee's overall summary and conclusions are presented in Chapter 4. Appendix A contains the USAID memorandum outlining the initial charge for this third CIN meeting. Appendix B offers guidance for further development of the diagnostic screens used in the SCI and comments on the nutritional diagnosis and management strategies for the three categories of children that will be identified. Appendix C lists references to articles made available to the committee members, and Appendix D provides excerpts of important components of the nutrition algorithms. ACKNOWLEDGMENTS The committee gives special thanks to the USAID staff from the Office of Health and Nutrition, who gave graciously of their time in providing information for the report. These included Susan Anthony, Al Bartlett, Kevin Callahan, Eunyong Chung, Cate Johnson, Caryn Miller, Samuel G. Kahn, and Andrew Siderski. The committee also thanks the following individuals for their important contributions to the evidentiary base considered in the preparation of the report: Robert E. Black, The Johns Hopkins School of Hygiene and Public Health; Caryn Bern, Centers for Disease Control and Prevention; Joanne Csete, United Nations Children's Fund (UNICEF); Katherine L. Dickin, The Manoff Group, Inc.; Mary S. Lung'aho, WellStart; and Ronald Waldman, The Basics Project. The committee would also like to express its appreciation to the IOM staff who facilitated the work of the CIN: Christopher P. Howson, study director; Jamaine L. Tinker, financial associate; Michael Edington, managing editor; Caroline McEuen, copy editor; Claudia Carl, administrative associate; and Gail Spears, administrative assistant. The committee especially thanks Susan M. Knasiak, research assistant, for her help in conducting the third meeting and for her valuable editorial advice in preparing the report draft. Finally, the committee thanks Richard G. Seifman, formerly at USAID; Polly

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Consideration of the Nutrition Components of the Sick Child Initiative Harrison, IOM; and Catherine Woteki, formerly of the FNB, for their vision and hard work in realizing this project, and Allison A. Yates, FNB, for her collaborative support of the CIN's activities. Lindsay H. Allen, Chair Committee on International Nutrition