Food supplementation with encouragement to feed it to infants from 4 to 12 months of age has a small impact on weight gain.

It is unclear whether a substantial decline in malnutrition among infants in developing countries can be achieved by increasing food availability and nutrition counseling without concurrent morbidity-reducing interventions. The study was designed to determine whether provision of generous amounts of a micronutrient-fortified food supplement supported by counseling or nutritional counseling alone would significantly improve physical growth between 4 and 12 mo of age. In a controlled trial, 418 infants 4 mo of age were individually randomized to one of the four groups and followed until 12 mo of age. The first group received a milk-based cereal and nutritional counseling; the second group monthly nutritional counseling alone. To control for the effect of twice-weekly home visits for morbidity ascertainment, similar visits were made in one of the control groups (visitation group); the fourth group received no intervention. The median energy intake from nonbreast milk sources was higher in the food supplementation group than in the visitation group by 1212 kJ at 26 wk (P < 0.001), 1739 kJ at 38 wk (P < 0.001) and 2257 kJ at 52 wk (P < 0.001). The food supplementation infants gained 250 g (95% confidence interval: 20--480 g) more weight than did the visitation group. The difference in the mean increment in length during the study was 0.4 cm (95% confidence interval: -0.1--0.9 cm). The nutritional counseling group had higher energy intakes ranging from 280 to 752 kJ at different ages (P < 0.05 at all ages) but no significant benefit on weight and length increments. Methods to enhance the impact of these interventions need to be identified.

Removing risk from safe motherhood.

It is necessary to differentiate between complications of pregnancy and population risk groups for those complications. The latter have limited use as most complications occur in the low risk groups. Complications of pregnancy need to be treated in health facilities that can provide blood transfusions, cesarean section, removal of placenta and induction of labor. A plan must exist for each pregnant woman to be moved to such a facility, since it is not possible to predict who will have the complication. Early detection and effective treatment of complications and family planning services to prevent unwanted pregnancies is the way to lower maternal mortality.

Surgical extraction of guinea worm: disability reduction and contribution to disease control.

Surgical extraction of Guinea worm prior to eruption through the skin has long been performed by traditional healers in India. Using modern aseptic techniques under local anesthesia, unerupted worms can be completely and painlessly removed in several minutes. As a result, the average number of working days lost due to a single worm is reduced from three weeks or more to three days. In the field, the procedure results not only in a dramatic decrease in Guinea worm associated disability, but also in an improvement in detecting cases, and appears to reduce disease transmission.

Infant feeding practices among patients of pediatricians and general practitioners.

In an attempt to document the infant feeding practices among patients of pediatricians and general practitioners, a study was carried over a period of one month and data of 10,374 infants were recorded using a pre-printed proforma marked by a simple 'tick' for each patient. The results showed: (i) initiation of breastfeeding was delayed in nearly half of the cases beyond 24 hours; (ii) introduction of bottle feeding in more than half of infants by the age of 4 months and (iii) introduction of solid foods later than eight months in almost half of infants. While breastfeeding is practised by 78% of women, only one in five practice exclusive breastfeeding till 4-6 months, and very few avoid bottle feeds. Much education and change in behaviour is needed if optimal benefit of breastfeeding in India is to be realised.

A strategy for reducing numbers? Response.

PIP: While there may be no documented evidence that mortality decline is a causative factor in demographic transition, there is a close association between reductions in mortality and fertility. The Indian experience of more than 40 years shows that consistent efforts in the promotion of family planning will be rewarded with demographic transition. In the Indian state of Kerala, population 30 million, improving child survival, female literacy, strict child labor laws, and effective high coverage primary health care reduced mortality and fertility. Its infant mortality rate is 22/100 births, which is 25% of the national average. Its birth rate is 20/1000 and is continuing to fall. In the past decade population growth was only 14% compared to 25% nationally and 28% in the northern states. If Kerala's figures were applied to all of India, there would be 2 million less infant deaths and 8 million less births. The impact of reducing infant mortality on population growth in raw numbers in insignificant. With a mortality rate of 150/1000 there are 850 survivors. If the mortality rate is cut in half there will be only a .18% increase in population, but with a 50% reduction in infant suffering and death. Historically such mortality declines are associated with a 25% or more decline in fertility. This is the reason that UNICEF has been a long-time advocate of child survival programs as an integral part of population control measures. Euthanasia is surely not the solution to the population problem. The daily loss of 40,000 childhood lives is a tragic part of the human experience. However, helping these children to become and stay healthy is the best method of reducing population.^ieng

Oral rehydration therapy: a community trial comparing the acceptability of homemade sucrose and cereal-based solutions.

Sugar-based oral rehydration therapy (ORT) for diarrhoea is promoted in many countries of the world. One programme in Bangladesh has instructed more than 13 million mothers in the preparation of a sugar-salt solution in the home; despite very high rates of correct mixing and knowledge, subsequent application was found in only some 20% of all diarrhoea episodes. Since rice is far more available in rural homes (95%) than any type of sugar (30%) and rice gruel is a widely accepted food during illness, a field trial was conducted in three areas (total population, 68,345) to compare the acceptability and use of rice-based ORT with that of sugar-based ORT. Although the mothers unanimously agreed that the rice-based solutions "stopped" the diarrhoea more quickly, they used the sugar-based solutions twice as often (in 40% of severe watery episodes) as the rice-based solutions (in 18%), because the rice-ORT was much more time-consuming and difficult to prepare. The observed reduced utilization of home-made rice-ORT makes it a poor substitute for sugar-ORT at the community level in rural Bangladesh.

PIP: Sugar-based oral rehydration therapy (ORT) for diarrhea is promoted in many countries in the world. 1 program in Bangladesh has instructed more than 13 million mothers in the preparation of a sugar-salt solution in the home; despite very high rates of correct mixing and knowledge, subsequent application was found in only some 20% of all diarrhea episodes. Since rice is far more available in rural homes (95%) than any type of sugar (30%) and rice gruel is a widely accepted food during illness, a field trial was conducted in 3 areas (total population=68,345) to compare the acceptability and use of rice-based ORT with that of sugar-based ORT. Although the mothers unanimously agreed that the rice-based solutions stopped the diarrhea more quickly, they used the sugar-based solutions twice as often (in 40% of severe watery episodes) as the rice-based solutions (in 18%), because the rice ORT was more time-consuming and difficult to prepare. The observed reduced utilization of homemade rice-ORT makes it a poor substitute for sugar-ORT at the community level in rural Bangladesh. (author's)

Principles and strategies of programming for adolescent girls.

PIP: In consort with the focus on women's enrichment and status improvement in developing countries, the following principles and strategies are discussed: decentralized planning, maximizing schooling, experiential learning, avoidance of exploitation. Planning must involve adolescents and women and be consistent with cultural influences and patterns. Girls also need to be encouraged by parents to stay in schools as long as possible, with minimizing the attractions of staying out of school, and provision for dropouts to return. Experiential learning through interaction, observation, and enjoyment is the best method and will work best with the disadvantaged and neglected, and enable women to, for instance, understand the importance of breastfeeding, immunization, or hygiene. The program which may involved service is not to be exploitative, be a convenience, and benefit her. The content needs to be flexible and suitable to the age such that nutrition must be taught before menarche and at the first sign of breast development, and when bone growth is at its peak. School feeding programs are of proven benefit. Goals can be satisfied without being rigid and allowing for dream time also. The shape of a better tomorrow will depend upon these women. Adequate funding is always necessary, and something for nothing doesn't work without adequate food, useful learning materials, and attractive incentives such as a culturally appropriate items of clothing, confidence and prestige building are a must. The challenges are to provide formal schooling and the concomitant self-esteem building and public recognition of women's competence. Seclusion of pubescent girls in purdah needs to be eliminated and replaced with programs of responsible, mature and positive interaction with older women, who provide leadership skills and linkages to larger society. Interactions between girls is also important with village based continuing education, and practical self-guided curricula. Vocational training in marketable skills contributes to the economy and independence. Awareness of legal rights and utilization of resources available in primary health care needs to be encouraged. Changes need to be made in family perceptions that allow women educational growth without neglect of family chores and responsibilities. Health programs need to assess adequate intake of iron and folic acid, and nutrition starting at menarche, and proper hygiene. Reproductive information must be provided.^ieng

Weighing scales: design and choices.

PIP: 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.^ieng

Beyond survival: promoting healthy growth.

PIP: 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 child's 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.^ieng

Growth chart design.

PIP: 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 child's 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.^ieng

Ten pitfalls of growth monitoring and promotion.

PIP: Growth monitoring programs are often considered failures. These failures often stem from a lack of understanding of program implementation. The 10 most common pitfalls of the system are listed as follows: 1) Health workers tend to desire a diagnostic curative approach to malnutrition where Growth Monitoring and Prevention (GM/P) is a preventative measure. 2) Most current nutrition and GM/P programs start with children who are already undernourished. GM/P's should start with infants. 3) Nutritional status is currently emphasized rather than growth. 4) Mothers need to participate in monitoring more than they are currently expected to. 5) Standard GM/P's are normally not conducted on an individual basis. GM/P's must focus on communication between mother and worker. 6) GMP is simple in concept, but certainly not easy to implement. 7) GM/P is usually conducted as an isolated nutritional activity instead of an all-encompassing primary health care service. 8) GM/P is carried out by health workers with minimal community participation. 9) Most GM/P's provide free supplemental foods as incentive for mothers to attend monthly meetings, but the food becomes a preoccupation instead of an incentive. 10) People have too many false expectations of the program that are not grounded in reality. If workers concentrated on the overall goals and objectives of GM/P, these programs would have a greater impact on the health care of children.^ieng

Feeding, feedback and sustenance of primary health care.

PIP: 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 child's 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.^ieng