A new classification of acute protein-energy malnutrition.

Current schemes to classify protein-energy malnutrition (PEM) in hospitalized children below 5 years of age in developing countries are of limited usefulness, because age is often not known and wasted children are insufficiently discriminated. In this study, a newly proposed scheme, based on the presence of wasting (weight-for-height < or = -2 z scores) and oedema, was compared with clinical and the original Wellcome criteria to classify PEM in 538 under-fives hospitalized for PEM in a rural hospital in Nchelenge, Zambia. Wasting in the absence of oedema was clinically false-positively diagnosed in 34.0 per cent, whereas the Wellcome classification gave rise to 28.6 per cent false-positive and 39.9 per cent false-negative diagnosis. In the presence of oedema, clinical diagnosis of wasting was 44.7 per cent false-positive and 41.4 per cent false-negative, while the Wellcome scheme had a false-negative rate of 54.3 per cent. We conclude that the Wellcome classification did not add to the clinical diagnostic accuracy of PEM as opposed to the proposed scheme, which merits further study. In an Appendix the use and calculation of z scores of weight-for-height is further explained.

Indigenous first feeding practices in newborn babies.

OBJECTIVE: To describe the common practices in indigenous first feeding of the newborn babies in countries of the continents of Africa, Asia and Latin America. METHODS: Anthropological, medical and nursing publications were searched for indigenous customs and beliefs concerning the first feed given to newborn babies. FINDINGS: From a nutritional point of view the first food is just symbolic but it has a function in either purifying and clearing the 'dirty' throat and bowel or to prepare the baby for adult life. CONCLUSIONS: The general withholding of colostrum should be abandoned and the indigenously strange custom of feeding water with sugar should be discouraged.

Mortality in severe protein-energy malnutrition at Nchelenge, Zambia.

At St Paul's Hospital, Nchelenge district, north-eastern Zambia, routine clinical management of 299 children up to 5 years of age with severe and/or complicated protein-energy malnutrition (PEM) was monitored and predictors of outcome analysed. PEM was typed according to a modified Wellcome classification. Overall mortality was 25.8 per cent with 13.4 per cent for kwashiorkor, 17.8 per cent for marasmus, 28.0 per cent for marasmic kwashiorkor, and 48.3 per cent for untyped cases of PEM. Mortality up to 18 months of age was related to the presence of dehydration, pneumonia or another infectious disorder, severe stunting, and a mid-upper arm circumference < or = 104 mm, suggesting that these children may have been born pre- and/or dysmaturely. At ages 19-60 months, the main predictor of mortality was pneumonia, with other infectious disorders and dehydration showing less impact. Routine administration of broad-spectrum antibiotics, irrespective of clinical signs of infection, is most probably the single most effective measure to reduce the high case-fatality rate due to PEM in developing countries.

Clinical epidemiology of paediatric disease at Nchelenge, north-east Zambia.

In a combined retrospective and prospective 4-year study of 6412 children consecutively admitted to St Paul's Hospital, Nchelenge, north-east Zambia, the clinical epidemiology of paediatric disease was described. One diagnosis per admission was noted. Protein-energy malnutrition (PEM) was diagnosed clinically and by means of a modified Wellcome scheme using weight-for-height and Z scores. Correlation coefficients were calculated between monthly admission rates and relative humidity, rainfall and temperature. The age distribution of admitted children showed several distinct groups. Type I (malaria, acute gastro-enteritis, pneumonia and meningitis) had its peak in the 1st 7 months of age, type II (burn wounds and measles) had its main prevalence between the ages of 2 and 4 years, and type III (trauma, typhoid fever, snake bite and tropical ulcer) occurred mainly between 4 and 14 years of age. Admission rates for PEM, PEM subtypes, pneumonia, trauma and snake bite correlated with wet season variables. Malaria and acute gastro-enteritis were extremely common throughout the year. A measles epidemic in the dry season was initially followed by an increase in marasmus, whereas oedematous malnutrition only assumed epidemic proportions associated with a post-measles rise in admission rates of pneumonia. Clinical epidemiological data at the district level is a powerful tool for understanding the pattern of serious paediatric disease in the community.

Physical growth of children under five years of age in Nchelenge, Zambia: results from a district survey.

This study focuses on the physical growth of children aged 0-60 months in Nchelenge District, northeast Zambia. By means of a two-stage clustered and random sampling method, 193 households were selected. Weight, height, and mid-upper-arm circumference (MUAC) of children 0-60 months were measured. Underweight, stunting, and wasting were defined as weight for age, height for age, and weight for height (W/H), respectively, < or = 2 z scores below the median of the National Center for Health Statistics (NCHS) reference population. Among 250 children, prevalence rates of 30% underweight, 69.2% stunting, and 4.4% wasting were found, with the highest rates at age 12- < 24 months. Prevalence of stunting, underweight, and wasting in children aged 0- < 6 months and 6- < 12 months suggested that a substantial proportion of infants were premature and/or small for gestational age. The literature suggests that prematurity and intrauterine growth retardation may be quite common in Africa, and this may have important implications for the interpretation of growth data and under nutrition rates. Use of the MUAC < 125 mm as an indicator of wasting resulted in higher estimates of wasting compared to W/H < or = -2 z scores, and seemed unsuitable as a screening test for wasting in this Zambian population.

Women in the central highlands of Irian Jaya, Indonesia.

The weight, height and mid-upper-arm circumference (MUAC) were measured in 159 women of reproductive age between June and November 1991 in four remote valleys in the Eastern Central Highlands of Irian Jaya, Indonesia. The average weight was 42.3 +/- 5.2 kg and 26% weighed less than 40 kg. The average height was 141.3 +/- 9.1 cm and 30% were shorter than 140 cm. By the MUAC measurement, the nutritional status was considered to be inadequate (MUAC less than 23 cm) in 58% of the women. 8% of the women were observed to be visibly pregnant and 43% were lactating. In the same period 112 women in the Yamil valley were visited at home. They had given birth to 331 children, of whom 83 had died before the age of five years, i.e. a child mortality rate of 251 per 1000 births. Nearly half of the mortality (45%) occurred shortly after birth.

PIP: To obtain baseline information to assist a new nurse-midwife, weight, height, and mid-upper-arm circumference (MUAC) were measured in 159 women of reproductive age in four remote valleys (Yamil, Hey, Moruman, and Bomela) in the Eastern Central Highlands of Irian Jaya, Indonesia, in 1991. Average weight was 42.3 +or- 5.2 kg; 26% weighed less than 40 kg. Height averaged 141.3 +or- 9.1 cm; 30% were shorter than 140 cm. The MUAC was less than 23 cm (indicative of inadequate nutrition) in 58% of the women and 20 cm or less (malnutrition) in 16%. The international reference standards for weight, height, and MUAC are 56.6 kg, 163.7 cm, and 26 cm. 8% of women appeared pregnant and 43% were lactating. Home visits to 112 women in the Yamil valley revealed they had given birth to 331 children, 83 of whom had died before 5 years of age (child mortality rate, 251/1000 births). Since maternal food supplementation aimed at increasing birth weight would lead to more complicated deliveries in stunted mothers, the most feasible strategy is a nutrition program for schoolchildren--the mothers of the next generation.

Absolute values or Z scores of mid-upper arm circumference to identify wasting? Evaluation in a community as well as a clinical sample of under fives from Nchelenge, Zambia.

The purpose of the study was to compare the use of absolute cut off values of the mid-upper arm circumference (MUAC) with age- and sex-adjusted z scores of the MUAC in the identification of acute undernutrition (wasting) in children up to 60 months of age. In Nchelenge, northern Zambia, 275 children from the community, selected by a two-stage cluster sampling procedure, and 105 hospitalized children with protein energy malnutrition (PEM) individually matched for age, sex, village and under-five clinic attendance with 104 controls, were clinically and anthropometrically (weight, height, MUAC) examined. zScores for weight for height and MUAC were calculated and PEM was classified according to a modified Wellcome scheme. For community prevalence rates of wasting in various age groups, MUAC < or = -4 z scores more closely paralleled W/H < or = -2 z scores than MUAC <125 mm. To identify individual children with wasting, MUAC < or = -2 z scores gave a better sensitivity than MUAC <125 mm. In hospitalized PEM children, z scores appeared to offer no advantages over absolute MUAC values in identifying the presence of wasting. Applicability of the MUAC and optimal cut off values may differ according to the setting in which the MUAC is to be applied.

Growth of under five-year-old children in Kyeni, Kenya.

During a three-months period a cross-sectional study of the measurements of head circumference, mid-upper-arm circumference (MUAC) and weight was performed in 515 under five-year-old children in Kyeni, Kenya. Growth of Kyeni children seems to develop according to international standards for weight-for-age, MUAC-for-age and head circumference and for all parameters the average remains above minus 2 SD of the standard. Despite the presence of anthropometric malnutrition and downward trend in weight-for-age, MUAC-for-age and to a lesser degree the head circumference-for-age, the average growth of the Kyeni children in Kenya is within normal limits of international references.

PIP: A cross-sectional study was performed during a 3-month period on 515 children 0-5 years old who attended the daily maternal and child health clinic of Consolata Hospital in Kyeni, Embu District, Kenya, to determine growth and nutritional status through weight-for-age, head circumference and mid-upper-arm circumference (MUAC). It was found that the average growth of these children developed according to international standards for the 3 parameters and remained above minus 2 standard deviations (SD). At age 4 months for females and 5 months for males, both sexes showed a downward trend in weight- for-age. With increasing age, a larger proportion fell below minus 2 SD of the standard (2.2% of the 0-3 month age group, 16.6% between 6 months and 5 years). This criterion revealed that an average 10.3% of the children were malnourished. However, since many of the children were stunted and weight-for-height was normal, the minus 2 SD is too high a criterion. The MUAC measurement, which reflects weigh-for-height, gives a more accurate figure of malnutrition. Using the Blankhart classification for this criterion, 3.7% of these children were malnourished and 16.0% were borderline for a total of 19.7% insufficiently nourished children. These estimates may also be too high and may result in too many children being classified as borderline, however, since they assume a constant MUAC from 6-60 months, which is not the case. Cross-tabulation of the data above age 6 months results in the presumably more realistic figure of 2.2% anthropometric malnutrition, 24.7% borderline, and 73.1% well nourished. It is recommended that MUAC be included in routine clinical measurements. In conclusion, despite the presence of anthropometric malnutrition and the age-related downward trend in indicators, the children exhibited average growth in terms of international standards.

Differences in physical growth of Aymara and Quechua children living at high altitude in Peru.

Physical growth of Amerindian children living in two Aymara and three Quechua peasant communities in the Andean highlands of southern Peru (altitude 3,810-3,840 m) was studied, taking into account differences in the microclimate, agronomic situation, and sociodemographic variables. Anthropometric measurements were taken in 395 children aged under 14 years of age in a sample of 151 families in these communities, who were surveyed for sociodemographic variables as well. Data on the land system were available for 77 families. In comparison with reference populations from the United States (NCHS) and The Netherlands, stature, weight, head circumference, and midupper arm circumference (but not weight for stature) in the sample children were reduced. Growth retardation increased after the age of 1 year. Stature and weight in the present sample were very similar compared with previously published data on growth of rural Aymara children living near Lake Titicaca in Bolivia. Head circumference, midupper arm circumference, and weight for stature were significantly larger in Aymara children compared with Quechua children. Land was significantly more fragmented in Aymara compared with Quechua families, but amount of land owned was not different. Perinatal and infant mortality was elevated in Aymara vs. Quechua communities. Most families in Aymara communities used protected drinking water. One Quechua community had a severe microclimate, grim economic outlook, and weak social cohesion. Children in this community showed significant reductions in weight and midupper arm circumference compared with their peers in the other communities. We conclude that (presumably nutritionally mediated) intervillage and Aymara-Quechua differences in childhood physical growth existed in this rural high-altitude population in Peru and were associated with microclimate and the village economy, sociodemographic factors, and differences in the land system.

Obstetrics and childbirth at the Aitape Health Centre, Papua New Guinea.

Routinely collected obstetric data at the Aitape Health Centre, Papua New Guinea over the years 1986, 1988 and 1989 were analyzed and compared with figures from western New Guinea of about thirty years ago and with those of rural African hospitals. Data from 924 deliveries were analyzed. 30% were born before arrival (BBA). The number of abnormal deliveries was high. This was in part due to the high frequency of twin births (4.5%). Among the BBAs puerperal sepsis and stillbirth were significantly higher than among those who delivered in the health centre. The stillbirth frequency was 3.4%. The sex ratio male:female at birth was 120.9. The large number of retained placentae with manual removal (5.2%) was related to high parity; 33.5% of the women delivering at the health centre were para-4 or more. 20% of male and 24% of female newborns had low birthweight (less than 2500g).

PIP: Routinely collected obstetric data at the Aitape Health Center, Papua New Guinea over the years 1986, 1988, and 1989 were analyzed and compared with figures form western New Guinea of about 30 years ago and with those of rural African hospitals. Data from 924 deliveries were analyzed. 30% were born before arrival (BBA) and the number of abnormal deliveries was high. This was due in part to the high frequency of twin births (4.5%). Among the BBAs, puerperal sepsis and stillbirth were significantly higher than among those who delivered in the health center. The stillbirth frequency was 3.4%. The sex ratio of males: females at birth was 120.9. The large number of retained placentae with manual removal (5.2%) was related to high parity--33% of the women who delivered at the health center were para 4 or higher. 20% of the male and 24% of the female newborns were classified as low birthweight (2500 g).

Immunisation and nutritional status of under-fives in rural Zambia.

PIP: In 1987 the nutritional status of Zambian children under 5 years of age was studied in 3 regions around Kamoto Hospital with the objective of exploring the prevalence if malnutrition and contributing factors such as maternal education and immunization status. Jumbe was within easy reach of the hospital with a relatively high standard of living. Masumba and Kakumbi were different areas in one region with their own health center further away from the hospital. Chibembe was isolated without good roads. The nutritional status of 1-5 year old children was measured by the Mid Upper Arm Circumference (MUAC). A questionnaire with 22 questions queried mothers about education, breast feeding, meals, water supply, and sanitation. A total of 1251 children were observed, 1222 under age 5, and 29 a little older. 40% of mothers had no education and 54% had some primary education (15.2% passed grade 4, 7.3% reached grade 6, and 18.2% finished grade 7). Less than 5% attended secondary school, and only 1% of mothers finished it. In Chibembe almost 50% of mothers had no education, secondary school education was the lowest of the regions, while in Jumbe was the highest. Immunizations included Bacillus Calmette-Guerin (BCG) at birth, diphtheria-tetanus-pertussis (DTP I, II, III, and a booster), oral polio vaccine (OPV) I, II, III, and a booster, and measles. The Chibembe region has the highest number of incomplete immunizations. In the Jumbe region unknown immunization presumably contributed to a higher number of older children. The nutritional status of children was the lowest in Chibembe region with a 10.8% rate of malnutrition and the lowest rate of maternal education. In Masumba/Kakumbi malnutrition was the lowest with 5.6%, while maternal education and complete immunization were the highest. The nutritional status of the completely immunized children was better. MUAC should be routinely employed for children under 5 years of age.^ieng

Result of treatment in children with tuberculosis. Evaluation of indications for and results of treatment in a 5 years cohort of children treated for tuberculosis in Turiani Hospital Tanzania.

Between January 1983 and January 1988 a total of 146 children started tuberculosis (TB) treatment in Turiani Hospital, Tanzania. During the treatment period 16 children died and another 16 were transferred out. From the remaining 114 children, 84 could be traced and were visited at home. Out of this group 85% were found to be in good clinical condition, whereas 7% had a moderate condition and 1% were seriously ill. Tuberculin sensitivity testing has been carried out in 53 children from the follow-up group. The indications for treatment and the results of the follow-up study are discussed.

Tuberculosis in children: treatment evaluation and results in a 5 year cohort of children with tuberculosis in Turiani Hospital, Tanzania.

Between January 1983 and January 1988, a total of 146 children started TB treatment in Turiani Hospital, Tanzania. During the treatment period 16 children died and another 16 have been transferred out. From the remaining 114, 84 could be traced and were visited at home. Out of this group, 85% were found to be in good clinical condition, and 1% was in bad shape. Death had occurred in 7% after finishing their treatment. Medical records of all children were analysed. Tuberculin sensitivity testing has been carried out in 53 children from the follow-up group. The indications for treatment and the results of the follow-up study are discussed.

PIP: Physicians began tuberculosis (TB) treatment on 146 children at Turiani Hospital in the Morogoro North district, Tanzania between January 1983-January 1988. 46% were 2 years old and 9% were 12 years old. Treatment consisted of daily doses of 20 mg/kg streptomycin and 15 mg/kg thiazina for the 8 week hospital stay followed by the same dose of thiazina for 10 months. Some cases also received rifampicin and pyrazinamide. They administered tubercullin sensitivity tests to 53 of the 84 children who could be traced and visited. Researchers followed the TB case to evaluate indications for and the results of TB treatment in children. The physicians began treatment in some case even though the cases did not exhibit clear symptoms of TB. 74% of the patients whose BCG status was recorded had earlier received a BCG vaccination. Research showed that BCG vaccination protects against 2 severe forms of TB, meningeal and milliary, both of which were not present in this population. At the end of 5 years, 7% (6) of the patients died and only 1% (1) was in poor condition. 85% of all follow up patients were in good condition and well nourished. Even most of the patients who ended treatment rather early after leaving the hospital (74%) were well. In fact, no significant difference in the condition between defaulters and patients who completed treatment existed. This showed that a shorter duration of treatment may be as effective as 10 months of treatment. Only 34% of tested children reacted to the tuberculin sensitivity test which could mean that physicians overtreated around 60% of the patients. 25% of the children who had a negative reaction had abcesses while none of those with a positive reaction had abcesses. In conclusion, physicians should administer a tuberculin sensitivity test at the end of the 8 weeks of treatment to prevent overtreatment.

Community health care and hospital attendance: a case study in rural Ghana.

This study assesses the influence of coverage with a network of PHC clinics as well as private clinics in Dormaa District, Ghana on, hospital attendance. This influence is measured by analysing hospital attendance among inhabitants during 6 months in 1984 and 1986. Several conditioning factors are analysed: the type of modern health care present in the community and the experience of the community health worker (CHW); the distance between community and hospital; the time factor (1984 and 1986); the sex and age of the attendants; the diagnosis made at the hospital. It appears that fewer people attend the hospital if a community participates in the PHC programme and if the CHW is experienced. When people from these communities attend the hospital they do so less unnecessarily than those from other communities. Simple analysis of routine hospital data may contribute to any PHC assessment programme set up around the hospital.