Ann Ashworth

WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors

BACKGROUND WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals. METHODS All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April, 2000 to April, 2001, were studied and their case-fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors. FINDINGS At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs 77%, p<0.0001), antibiotics with gram-negative cover (15% vs 46%, p=0.0003), and vitamin A (76% vs 91%, p=0.018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000-01 were due to doctor error and 28% to nurse error. Weaknesses within the health system--especially doctor training, and nurse supervision and support--compromised quality of care. INTERPRETATION Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths.

Comparison of the effect of two systems for the promotion of exclusive breastfeeding

BACKGROUND Promotion of breastfeeding is an important child-survival intervention, yet little is known about which promotional strategies are the most effective. We aimed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil--a hospital-based system and the same system combined with a programme of home visits. METHODS In February, 2001, maternity staff from two hospitals in Pernambuco, Brazil, were trained according to the Baby-Friendly Hospital Initiative (BFHI). In a randomised trial between March and August, 2001, 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding (n=175) or no home visits (n=175). Breastfeeding practices were studied on days 1, 10, 30, 60, 90, 120, 150, and 180 by researchers unaware of group allocation. The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months. Analyses were by intention to treat. FINDINGS The hospital-training intervention achieved a high rate (70%) of exclusive breastfeeding in the hospitals, but this rate was not sustained at home and at 10 days of age only 30% of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10-180 differed significantly (p<0.0001), with a mean aggregated prevalence of 45% among the group assigned home visits compared with 13% for the group assigned none. INTERPRETATION The BFHI achieves high rates of exclusive breastfeeding in hospital; however, in Brazil at least, the rates fall rapidly thereafter. Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed. A combination of promotional systems (hospital-based and in the community) is needed.

Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaïre

To date questionnaire surveys have been the most commonly used instruments to measure hygiene behaviours related to water and sanitation. More recently, a number of studies have used structured observations to study practices related to diarrhoea. During a trial of a hygiene education intervention to reduce diarrhoea among young children in Bandundu, Zaire, both instruments were used to measure the disposal of child faeces and various hand‐washing practices. Three hundred families were observed and follow‐up interviews performed with 274 (91%) mothers. At the individual level, agreement between observed and reported behaviour was little better than might be expected by chance. There was evidence of over‐reporting of hand‐washing before food preparation (44%vs 33%; P= 0.03), hand‐washing before eating (76%vs 60%; P < 0.001) and disposal of the child’s faeces in a latrine (75%vs 40%; P < 0.001). On the other hand, hand‐washing before feeding the child was reported less often than it was observed (7%vs 64%; P < 0.001). Our data are consistent with the hypothesis that, in general, mothers over‐report ‘desirable’ behaviours. At the same time, our data indicate that open questions may lead to under‐reporting of certain behaviours. The repeatability of observations at both the individual and population levels remains to be established.

Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil

Objective: To test whether zinc supplementation reduces the deficits in mental development and behaviour that are found in term infants of low birth weight in the study population.Design: A prospective double-blind, part-randomised efficacy trial.Setting: A low-income population in Pernambuco, northeast Brazil, where the economy is largely dependent on sugar-cane production, and where over 90% of deliveries occur in health facilities.Subjects: During a 20-month period, all singleton, term infants weighing 1500–2499 g born to families of low income (<US 

Prevalence of anemia in children 6-59 months old in the state of Pernambuco, Brazil

280/month) were enroled at birth (n=205). At 6 and 12-months, the numbers tested were 163 and 138 respectively.Intervention: Infants born from January 1993–January 1994 were randomly assigned to receive daily, except Sundays, a placebo (n=66) or 1 mg zinc (n=68). Those born February–August 1994 were given 5 mg zinc (n=71). Supplementation was for eight weeks, starting at birth. Field workers visited each infant at home to administer the supplement.Results: At 6 and 12-months, mental and psychomotor development was assessed with the Bayley Scales of Infant Development and no significant differences in the scores of the three groups were found. At 12-months, behaviour was also assessed on 5 ratings. Ratings were highest in infants given 5 mg zinc (P=0.042).Conclusions: Zinc supplementation (5 mg/d) for eight weeks may reverse some of the poor behaviours, particularly responsiveness, exhibited by low birth weight infants. No amelioration of their mental and psychomotor deficits was found.Sponsorship: The Wellcome Trust, United Kingdom, provided financial support (Grant no. 036605/Z/92). Dr Lira was supported by CAPES (Fundação Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), Brazil.

Preventing HIV transmission to children : Quality of counselling of mothers in South Africa

OBJECTIVE To determine the prevalence of anemia in children 6-59 months old in Pernambuco, a state in northeastern Brazil, so as to help guide health and nutrition policies there. METHODS In 1997 a representative sample of 777 young children had their hemoglobin concentration measured. The sampling process was in three stages. First, 18 municipalities were randomly selected to represent the state and its three geographic areas (metropolitan region of Recife, urban interior, and rural interior). Next, using census lists, 45 census sectors were randomly chosen. Finally, 777 children aged 6-59 months old were selected. Blood was collected by venipuncture, and hemoglobin was measured with a portable hemoglobinometer. In the analysis, prevalence was weighted to reflect the census age distribution. RESULTS The prevalence of anemia among children 6-59 months old was 40.9% for the state as a whole. Prevalence in the metropolitan region of Recife was 39.6%, and it was 35.9% in the urban interior. The rural interior had the highest prevalence, 51.4%. Prevalence was twice as high in children aged 6-23 months as among those 24-59 months old, 61.8% vs. 31.0% (chi 2 = 77.9, P < 0.001). The mean hemoglobin concentrations in the younger and older age groups were 10.4 g/dL (standard deviation (SD) = 1.5) and 11.4 g/dL (SD = 1.4), respectively. There was no statistically significant difference between the sexes in terms of prevalence. CONCLUSIONS This is the first statewide assessment of anemia prevalence among young children in Brazil. Given the very high prevalence of anemia among the children studied in Pernambuco, especially those in the age group of 6-23 months, public health interventions are needed.

Efficacy and Effectiveness of Community-Based Treatment of Severe Malnutrition

Aim: To assess the quality of counselling provided to mothers through the programme to prevent mother‐to‐child transmission (PMTCT) of HIV in South Africa. Methods: Structured observations of consultations and exit interviews with 60 mothers attending clinics at three purposively selected PMTCT sites across South Africa were conducted. Results: Twenty‐two counsellors were observed. The general quality of communication skills was very good, and 73% of HIV‐negative mothers were informed of the advantages of exclusive breastfeeding (EBF). However, only one of 34 HIV‐positive mothers was informed about the possible side effects of nevirapine, and none was told what to do when it occurred. Only two HIV‐positive mothers were asked about essential conditions for safe formula feeding before a decision about an infant feeding option was made. None of the 12 mothers choosing to breastfeed was shown how to position the baby correctly on the breast or asked whether they thought EBF was feasible. Fewer than a quarter of mothers expressed confidence in performing the actions required, and 85% could not define the term EBF.

Controlled trial of three approaches to the treatment of severe malnutrition.

Background There is a long tradition of community-based rehabilitation for treatment of severe malnutrition: the question is whether it is effective and whether it should be advised for routine health systems. Objective To examine the effectiveness of rehabilitating severely malnourished children in the community in nonemergency situations. Methods A literature search was conducted of community-based rehabilitation programs delivered by day-care nutrition centers, residential nutrition centers, primary health clinics, and domiciliary care with or without provision of food, for the period 1980–2005. Effectiveness was defined as mortality of less than 5% and an average weight gain of at least 5 g/kg/day. Results Thirty-three studies of community-based rehabilitation were examined and summarized. Eleven (33%) programs were considered effective. Of the sub-sample of programs reported since 1995, 8 of 13 (62%) were effective. None of the programs operating within routine health systems without external assistance was effective. Conclusions With careful planning and resources, all four delivery systems can be effective. It is unlikely that a single delivery system would suit all situations worldwide. The choice of a system depends on local factors. High energy intakes (> 150 kcal/kg/day), high protein intakes (4–6 g/kg/day), and provision of micronutrients are essential for success. When done well, rehabilitation at home with family foods is more cost-effective than inpatient care, but the cost effectiveness of ready-to-use therapeutic foods (RUTF) versus family foods has not been studied. Where children have access to a functioning primary health-care system and can be monitored, the rehabilitation phase of treatment of severe malnutrition should take place in the community rather than in the hospital but only if caregivers can make energy- and protein-dense food mixtures or are given RUTF. For routine health services, the cost of RUTF, logistics of procurement and distribution, and sustainability need to be carefully considered.

Effect of zinc supplementation on the morbidity, immune function, and growth of low-birth-weight, full-term infants in northeast Brazil.

Domiciliary treatment of severely malnourished children could have economic and practical advantages over other methods. We compared three approaches in a controlled trial. 437 children in Dhaka (< 60% weight-for-height, and/or oedema) aged 12-60 months were sequentially allocated to treatment as inpatients, to day-care, or to care at home after one week of day-care. Institutional and parental costs incurred to reach 80% weight-for-height were compared. Costs for inpatient, day-care, and at-home groups averaged 6363, 2517, and 1552 taka (60 taka = UK pound 1). Mortality was low (< 5%) in all three groups. Day-care treatment approached inpatient care for speed of recovery at less than half the cost, but it was unpopular with parents. The at-home group took significantly longer to attain 80% weight-for-height than the other groups, but did so at the lowest average cost. Parental costs were highest for the at-home group as no food supplements were provided; nevertheless this was the most popular option. We conclude that at-home management of severely malnourished children after 1 week of inpatient care is a cost-effective strategy.

Faltering in infant growth in less-developed countries.

In Brazil, the highest incidence of low birth weight (LBW) occurs in the northeast, and diarrhea and respiratory infections are the main causes of infant mortality and morbidity. We hypothesized that LBW infants may be zinc deficient, and that this might be adversely affecting their immune function, morbidity, and postnatal growth. We therefore examined the effect of zinc supplementation on these outcomes during the first 6 mo of life. LBW full-term infants (mean birth weight 2337 g) were given daily for 8 wk either 5 mg Zn (n = 71), 1 mg Zn (n = 68), or a placebo (n = 66). Morbidity was determined prospectively through daily home visits (except on Sunday) during weeks 0-8, then twice weekly in weeks 9-26. Anthropometric measurements were made at 0, 4, 8, 17, and 26 wk. Immune function was assessed at 8 wk by the phytohemagglutinin skin test. Supplementation (5 mg Zn) was associated with a 28% reduction in diarrhea prevalence over the 6-mo period [after adjustment for confounders (P = 0.043)], and a 33% reduction in the prevalence of cough (NS, adjusted prevalence P = 0.073). All infants had a positive immune response at 8 wk. Although supplementation had no significant effect on weight and length gains from 0 to 26 wk, infants given 5 mg Zn gained more weight than infants given placebo during weeks 17-26 (P = 0.024, analysis of variance). There was no effect on any outcome with 1 mg Zn. We conclude that 5 mg Zn/d is of benefit to LBW, full-term infants who only have a modest weight deficit.