Jon Eliot Rohde

Bacteria, parasitic agents and rotaviruses associated with acute diarrhoea in hospital in-patient Indonesian children

Faeces from children (aged from one month to 12 years) with acute diarrhoea admitted to hospital in Yogyakarta, Indonesia, from June 1978 to June 1979, were examined for the presence of enteric pathogens. One or more recognized enteropathogens were identified in 56% of children. Rotaviruses were identified in 38% of all children. Toxigenic coliforms (predominantly Escherichia coli) were isolated from 12% of children. Salmonella sp. (6%), Shigella sp. (4%) and enteropathogenic parasites (predominantly Trichuris trichiura) from 3.5% of children. Mixed infections with two or more enteric pathogens were found in 7.6% of children. The incidence rate of each pathogen was correlated with age of the child, socio-economic level of the family and duration of breast feeding. Toxigenic coliforms were equally common in all age groups from both well-to-do and poor families. Enteropathogenic parasites appeared in increasing frequency with age. They were more common in artificially fed children and in children from families of low socio-economic level. The occurrence of multiple infection with mixtures of enteric pathogens increased with increasing age. Mixtures of parasites and other enteric pathogens only occurred in children with acute diarrhoea. These results provide baseline data about the relative importance of different enteropathogens in Indonesian children.

Bacterial contamination and dilution of milk in infant feeding bottles.

Unacceptably high bacterial counts have been found in infant feeding bottles particularly in developing areas. The process of bottlefeeding itself rather than the milk per se appears to be the major culprit. This study examines the dilution and bacterial contamination of infant feeding bottles in Indonesia. Mothers of 2 urban MCH (maternal child health) clinics and 2 rural health centers provided 10 ml. sample of milk from the bottlesthey were using to feed their infants. Samples were processed in the microbiology laboratory within 2 hours. Aerobic and anerobic cultures identified E. coli pathogens. Dilutional studies were done by measuring total nitrogen by Kjeldahl method. As a control 2 carefully prepared bottles were fed to 2 infants. Bottle contents after feeding were sampled and analyzed. The results showed that 3/4 of the milk bottles had greater than 100000 bacteria per ml. and E. coli was the predominant organism found. The mothers in this study came from a very highly educated group by Indonesian standards. However neither the degree of contamination nor dilution correlated with attained educational level of the mothers. Greater attention must be given to mothers who are bottlefeeding their babies to insure proper use of this potentially dangerous modern feeding apparatus.

Beyond survival : promoting healthy growth

Growth monitoring and nutritional assessment, as means to detect malnutrition, are 2 different types of programs in terms of conception, purposes, and execution. Growth monitoring starts as detection of malnutrition, then acts through prevention by communication to mothers, and finally utilizes community participation in total primary care. Nutritional assessment is a tool used to measure undernutrition. mainly in children. Emphasis is on curative or supplemental measures. Those children that are malnourished due to infections, low quality diet, poor breastfeeding, or maternal high fertility tend to have markedly stunted physical growth. Growth promotion, as a preventative strategy, relies on the cooperation of the mother to monitor and communicate stunting of her children. Growth Monitoring and Promotion (GMP) has recently been well defined at an Indian national meeting. GMP is preventative, promotive, and preemptive; it focuses on behavioral change; it works with the childs complete environment; and it affords responsibility to the mothers. GMP starts when a child is very young, before nutritional assessments determine the existence of malnutrition, and it creates an interactive community pertaining to health care.

Ten pitfalls of growth monitoring and promotion

ConclusionsWhile these ten pitfalls cover a wide array of common problems encountered in growth monitoring activities which we have seen throughout the world, there are undoubtedly other answers and approaches to improving growth and development of children. Careful attention to the overall goals and clear objectives of GM/P would, we believe, lead most workers to reject the present activities classified as ‘growth monitoring’ and recognize that it is unrealistic to expect their present organization and activity to bring about major changes in nutritional status or health of children in a given community. We do believe that with careful attention to the basic principles underlying the promotion of healthy growth in children, as a preventive home based and community activity, that growth monitoring and promotion programs can play a vital role in assuring optimal health, nutrition and well being of the children, even in the most deprived community.

Feeding, feedback and sustenance of primary health care

The neglect of nutrition in primary health care is widespread despite the severity of malnutrition in the world today. Some of the reasons for this situation include a lack of definition, i.e. nutrition is considered a continuous daily need, not a health intervention; it is often a difficult task to solicit participation from the mothers; nutrition is often not an acutely felt need, thus there is no demand; nutrition requires continuous action on a daily basis, but produces no visible results; and finally actions aimed at malnutrition or even its prevention often do not seem to work. Nutrition interventions often do not work because the interventions come too late, often when permanent stunting of the childs growth has already occurred. Since inadequate nutrition can not be seen in the early stages, growth monitoring can be used as a feedback mechanism to stimulate appropriate feeding responses. For a mother to become involved in growth monitoring 4 elements are necessary: 1) she must be aware of the problem or situation, 2) she must be motivated to respond, 3) she must have the knowledge and skills of how to feed, what to feed, and when to feed, and 4) She must have the means to act, i.e. food must be available to give the child. Many growth monitoring programs have failed because the mother was not involved, and never perceives the problem, therefore she never acts. If growth monitoring is integrated into the primary health care system, it also becomes a regular time for health education in other topics. Disease and death are more often found in children who are malnourished, thus primary health care interventions are likely to be more effective in the presence of effective nutrition interventions.

Growth chart design

Weight charts should reflect growth instead of just nutritional status. Growth charts show the dynamic growth process and help mothers understand this process. The chart should make growth tangible to the childs mother, create a need for growth, detect growth faltering, reinforce growth behavior, show negative effects of certain circumstances on growth, and should show the mother how to alleviate growth problems. Charts should include long linear accentuation of the vertical scale, prominently displayed trend lines (normal, decreasing, and flat growth), accurate plotting through chart organization, attractiveness and durability, an age range of 3 years old, and elimination of nutritional status trend lines. Growth charts are powerful educational tools and must be carefully designed for growth monitoring and promotion programs. A sample growth card is included with the article.

Mother milk and the Indonesian economy: a major national resource.

The economic value of mother milk in Indonesia is estimated as US

Growth monitoring as entry point for primary health care.

520 million, by calculating its direct-net food value, plus the saving in national health expenditures consequent to its use, plus cost of equivalent fertility reduction. However diverse influences are at work to undermine this national resource. Strong action by the Government is required to prevent this economic loss.

Weighing scales: design and choices.

The concept of a periodic village gathering for the provision of primary health care has evolved during the last fifteen years in Haiti from a mass immunization gathering in public market places to a smaller and more frequent village based meeting of mothers with their small children providing regular growth monitoring and a number of services on a monthly basis. While the expense of the mobile team has precluded the extension to the entire country, the exclusive village based approach suffers from lack of supervision, guidance and logistical support when left to the exclusive responsibility of villagers themselves. Haiti is now embarking on a major effort with government and private organizations alike to provide essential primary health care services through village based rallies supported by supervision and ancilliary services from the nearest fixed health facility. While technical effectiveness as measured by reduction in mortality has been proven, we continue to evolve a managerial strategy which will assure high coverage primary health care at affordable cost to the majority of underserved rural Haitians as we attempt to assure Health For All before the Year 2000 in Haiti.

Taking Science Where the Diarrhoea Is

This review discusses the use of weighing scales in India that have been provided by UNICEF. Evaluation of each type of scale covers criteria of scale design, scale acceptability, scale accuracy, scale operator error potential, and general economic considerations. Each criteria is assigned a maximum point value which is then divided into sub-criteria. The review describes and evaluates each of the following types of scales: bathroom, clinical beam basic bar, improved bar, spring dial, tubular spring, direct reading spring, electronic hanging, and electronic walk on. Emphasis is placed on price, simplicity, and accuracy. Scale maintenance and recalibration are important. Scale choice depends on goals of specific programs, economics, and acceptability of the technology. Electronic scales seem to be optimal for most considerations.