Overview
This page will aim to keep up an on-going discussion on best practices and new ideas in nutrition. It won’t be a “how to” guide on nutritional rehabilitation as so many excellent guides are available. One very useful overview is the chapter on the rehabilitation of children with malnutrition in Ted Lankester’s “Setting up Community Health Programmes”. It is also important to read the National Nutritional Protocols of the country in which you are working. The WHO guidelines on the treatment of malnutrition is a useful reference (as is their Global Strategy on Infant and Young Child Feeding), but should also be read in conjunction with the recent developments in the rehabilitation of children with Severe Acute Malnutrition [SAM]. A good summary of this is found in the Lancet article: Management of severe acute malnutrition in children
Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A
The Lancet 2006; 368:1992-2000
http://dx.doi.org/10.1016/S0140-6736(06)69443-9
Steve Collins & Co of Valid International, with support from Concern Worldwide and other international NGOs, have helped to revolutioniSe the rehabilitation of children with SAM, via a community based therapeutic care (CTC) approach. Just as the increased take up of measles vaccination has prevented an estimated further 7.5 million childhood deaths between 1999 and 2005 [see The Lancet, vol 369 January 20, 2007 “Has the 2005 measles mortality reduction goal been achieved?”], the use of ready-to-use therapeutic foods (RUTF) for children with severe acute malnutrition has the potential to dramatically prevent millions of childhood deaths. More on this in future pages.
DIFFERENT TYPES OF MALNUTRITION
Malnutrition can be either acute or chronic. Undernutrition can be acute or chronic malnutrition. Acute malnutrition, in severe forms seen as wasting (thinness, decrease in the bulk of muscle and fatty tissues) or Kwashiorkor (oedematous malnutrition) and is measured comparing weight with height. Two particularly well known forms of wasting are marasmus and kwashiorkor, are usually also associated with micronutrient deficiency. Micronutrients include things like iron, folic acid, iodine, zinc, selenium, and vitamin A. Chronic malnutrition is known as stunting (short height/ stature) and is measured comparing height with age. Malnutrition can be moderate (70 – 80% of the reference median) or severe (< 70% of the reference median). The mid-upper arm circumference (MUAC) is a very useful tool for quickly screening children with MUAC in the red zone closely linked with increased mortality. MUAC is used as a measure of acute malnutrition as the rapid weight loss is reflected in muscle wastage which is not linked to chronic malnutrition. It measures something different to weight for height so both measures are used for admission in many national protocols with <11.0cm MUAC accepted as an admission criteria in the revised WHO guidelines. Growth faltering (underweight) is a form of malnutrition referring to both acute and chronic malnutrition.
CAUSES OF MALNUTRITION
The causes of malnutrition are numerous, and ultimately are related to a lack of resources, knowledge and opportunity. As health workers, we have to work very closely with civil society and governments if we want to make a long term difference. Rehabilitation of malnourished children can not be carried out in isolation without trying to work on the root causes. For example, increased birth spacing and improving the diets of pregnant women can prevent stunting in their children. Nutritional thinking for preventing both acute and chronic malnutrition need to be incorporated into wider health services.
Malnutrition should be treated in the context of other childhood illnesses, as part of WHO’s Integrated Management of Childhood Illness (IMCI) approach, which is being expanded by UNICEF into their Accelerated Strategy on Child Survival and Development”. This includes the promotion of exclusive breastfeeding for six months and of appropriate feeding practices until 24 months; immunisation; Vitamin A distribution; control of anaemia for pregnant women and young children; de-worming; distribution of impregnated bed nets; promotion of iodised salt and prevention of low birth weight through antenatal care. Nutrition should be integrated into national health services .
It is economically sensible to invest in nutritional programmes as they reduce the cost of health care, promotes education and child development, improves economic growth and productivity for a country. [for more on this read the UN’s Standing Committee on Nutrition’s 2007 Strategic Framework, which is also good on the rights based approach to under and over nutrition for the elimination of poverty, and Millennium Development Goals]. Nutritional interventions need to be mainstreamed within health and development planning , recognising that good nutrition is not only an outcome of productive economic development but an essential element to achieving it. A two-thirds reduction in deaths in children from pneumonia occurred in the US in the early twentieth century before the advent of antibiotics in 1938 because of improvements in childhood nutrition and in living standards.
Children are nutrition insecure because :
- They lack access to age-appropriate foods
- They lack access to age-appropriate feeding practices (and proper weaning/exclusive breast feeding)
- They lack access to essential health services, infectious disease
- They lack access to safe water and hygiene practices
- They are born with a low birth weight
- The low status of women in society
MANAGEMENT STRATEGY FOR MALNUTRITION
Integrating nutrition into health services includes activities such as the following:
1. Ensuring that pregnant women have access to antenatal care
2. Promoting exclusive breastfeeding until six months and the timely introduction of adequate complementary foods
3. Hygiene promotion and making clean drinking water available
4. Ensuring that children are fully immunised
5. Ensuring that children in malaria-endemic areas sleep under insecticide-treated bed nets
6. Ensuring early and appropriate treatment of diseases, especially malaria and diarrhoea
7. Ensuring adequate multiple micronutrient supplementation for children and pregnant women
8. Growth monitoring at health service level
9. Nutritional surveillance at household level
10. Nutritional rehabilitation for severely and moderately malnourished children
OVER-NUTRITION
As bad as under-nutrition is over-nutrition (when a person surpasses their Body Mass Index (BMI)of 25, and they are further classified as obese when the BMI surpasses 30). This affects 300 million people in the world, with untold consequences on their long term health, related to heart disease, diabetes, high blood pressure, strokes, cancers and many other illnesses. This is now termed Nutrition Related Chronic Disease (NRCD). Believe it or not obesity is often related to poverty. Half a million people in Western Europe and the United States die every year from disease related to obesity. Read WHO’s Global Strategy on Diet, Physical Exercise and Health. In future web pages you will here more on this scourge of the modern world.
More in future editions on:
- CTC (Community-based Therapeutic Care for the rehabilitation of acutely malnourished children) and RUTF (ready-to-use therapeutic foods) not to mention locally made foods; MUAC;
- sustainable community based nutritional programmes;
- the causes of malnutrition; - nutritional monitoring and nutritional surveys;
- micronutrient deficiencies;
- nutrition and children with HIV;
- breast feeding;
- obesity and poverty;
- nutrition and displaced people;
- emergency thresholds;
- undernutrition and child development;
- age-appropriate feeding practices;
- food security;
- malnutrition – the global problem; and much more.
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Excerpt from setting up community Health programmes by Ted Lankester
No loud emergency, no famine, no drought, no flood has ever killed 250,000 children in a week. Yet a silent emergency does that – every week.
The chief killers in this silent emergency are pneumonia, diarrhoea, measles, malaria – and malnutrition.
A recent UNICEF report states that almost one third of all children in developing countries have malnutrition. Areas worst affected are south Asia and Africa.
Malnutrition contributes to more than half of all childhood deaths. Adequate nutrition is essential to help the body fight common childhood illnesses and is also important in TB and HIV/AIDS.
To tackle malnutrition at the local level, does not need a large number of doctors, huge sums of money or expensive equipment. What it does need is an enthusiastic health team and good management.
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Practices members have applied in their own situations
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This topic is convened by: |
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Dr Nigel Pearson
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