Scaling Up Improved Inpatient Treatment of Severe Malnutrition: Key Factors and Experiences From South Africa, Bolivia, Malawi, and Ghana.

Severe acute malnutrition (SAM) can have high mortality, especially in very ill children treated in the hospital. Many medical and nursing schools do not adequately, if at all, teach how to manage children with SAM. There is a dearth of experienced practitioners and trainers to serve as exemplars of good practice or participate in capacity development. We consider 4 country studies of scaling up implementation of WHO guidelines for improving the inpatient management of SAM within under-resourced public sector health services in South Africa, Bolivia, Malawi, and Ghana. Drawing on implementation reports, qualitative and quantitative data from our research, prospective and retrospective data collection, self-reflection, and our shared experiences, we review our capacity-building approaches for improving quality of care, implementation effectiveness, and lessons learned. These country studies provide important evidence that improved inpatient management of SAM is scalable in routine health services and scalability is achievable within different contexts and health systems. Effectiveness in reducing inpatient SAM deaths appears to be retained at scale.The country studies show evidence of impact on mortality early in the implementation and scaling-up process. However, it took many years to build workforce capacity, establish monitoring and mentoring procedures, and institutionalize the guidelines within health systems. Key features for success included collaborations to build capacity and undertake operational research and advocacy for guideline adoption; specialist teams to mentor and build confidence and competency through supportive supervision; and political commitment and administrative policies for sustainability. For frontline staff to be confident in their ability to deliver appropriate care competently, an enabling environment and supportive policies and processes are needed at all levels of the health system.

Anemia in Bolivian children: a comparative analysis among three regions of different altitudes.

Here, we analyzed four population-based demographic and health surveys conducted in Bolivia between 1998 and 2016 to understand trends in anemia in children from 6 to 59 months of age by selected sociodemographic characteristics and three categories of altitude: low, medium, and high. Over the 18-year period, the prevalence of anemia was virtually unchanged while that in children living at high altitude increased. Anemia in children living at all three altitude categories is more than 40% and a severe public health problem according to the World Health Organization. We did not identify a single consistent risk factor for anemia in children living at high altitude compared with those living at medium or low altitude. The most consistent characteristic associated with childhood anemia across the three altitude categories was diarrhea in the last 2 weeks. Low length/height for age, an adolescent or anemic mother, a mother with no or little education, and a mother who speaks Quechua or Aymara were also risk factors. We conclude that it is necessary to review anemia policies and programs and prioritize children who are at greatest risk of developing anemia, particularly those living at high altitude. As iron deficiency appears to explain only a small part of childhood anemia, there is also a need to better understand its other causes and develop appropriate interventions.

Nutritional status and human milk intake of exclusively breast-fed infants at high altitude in La Paz, Bolivia.

Breast-feeding habits are related to the nutritional status and the risk of illness and death in children under 2 years of age. For the first 6 months, infants should be exclusively breast-fed. This study aimed to evaluate the relationship between the infant's nutritional status and human milk intake by breast-fed infants at high altitude. A quantitative, descriptive, correlational study was conducted including mother/baby pairs of infants aged 2-6 months. The amount of human milk consumed by the infants was assessed by the deuterium oxide dose-to-mother technique. The lipid content of human milk was measured by creamatocrit, and anthropometric measurements were performed. A total of eighteen mother/baby pairs were assessed. The mean human milk intake was 888 (sd 149) g/d, and the intake of water from other sources was 24·3 (sd 29·8) g/d. The lipid content in human milk was 41 (sd 12) g/l. The infant's nutritional indicators were normal in all cases. A moderate positive correlation was found between milk volume and z scores weight-for-length r 0·58 (P=0·01), BMI-for-age r 0·56 (P=0·01) and weight-for-age r 0·45 (P=0·05). There was no correlation with length-for-age z score. The mean of breast milk intake in this study was similar to that found in other studies in the world. The lipid content is comparable to similar studies and was within the normal range. Children older than 3 months showed signs of stunting despite adequate volume and lipid content of breast milk.

Effects of a home-based participatory play intervention on infant and young child nutrition: a randomised evaluation among low-income households in El Alto, Bolivia.

BACKGROUND: Stunting affects child survival and is a key indicator of child well-being. Therefore, reducing stunting is a global goal. Improving infant and young child feeding (IYCF) practices is a recommended approach to reduce the risk of mortality and ameliorate nutritional status. Behavioural change interventions have the potential to improve IYCF practices. METHODS: We evaluated the effectiveness of an innovative behavioural change strategy on caregiver's knowledge, IYCF practices and nutritional status of children from low-income households in El Alto, Bolivia. Home visits used culturally adapted participatory play strategies to promote recommended IYCF practices. A total of 2014 households with children younger than 12 months at baseline were randomly assigned to treatment and control groups. FINDINGS: Caregiver knowledge and IYCF practices improved by 0.2 SD, as did food expenditures on recommended foods and dietary diversity. No significant effects were detected on anthropometric indicators or anaemia. Treatment compliance was 88% of households at enrolment and 66% at completion. INTERPRETATION: Participatory play-based behavioural change strategies are a promising delivery model to improve recommended IYCF practices. After 30 months of intervention, we found sustained positive effects on caregiver's knowledge and IYCF practices but no effect on nutritional status. Despite the lack of effect on linear growth and anaemia, our results highlight the relevance of implementing interventions that improve IYCF practices due to their importance for early development and prevention of obesity. Other contextual variables, apart from diet, that could be limiting children's growth potential in this population need to be identified to design holistic approaches that improve child well-being and human capital.

Peri-Urban, but Not Urban, Residence in Bolivia Is Associated with Higher Odds of Co-Occurrence of Overweight and Anemia among Young Children, and of Households with an Overweight Woman and Stunted Child.

Background: Urban populations have grown globally alongside emerging simultaneous burdens of undernutrition and obesity. Yet, how heterogeneous urban environments are associated with this nutritional double burden is poorly understood. Objective: We aimed to determine: 1) the prevalence of the nutritional double burden and its components in urban, peri-urban, and rural areas of Bolivia; and 2) the association of residence in these areas with the nutritional double burden and its components. Design: We surveyed 3946 randomly selected households from 2 metropolitan regions of Bolivia. Census data and remotely sensed imagery were used to define urban, peri-urban, and rural districts along a transect in each region. We defined 5 nutritional double burdens: concurrent overweight and anemia among women of reproductive age (15-49 y), and children (6-59 mo), respectively; concurrent overweight and stunting among children; and households with an overweight woman and, respectively, an anemic or stunted child. Capillary hemoglobin concentrations were measured to assess anemia (women: hemoglobin <120 g/L; children: hemoglobin <110 g/L), and overweight and stunting were calculated from height, weight, and age data. Results: In multiple logistic regression models, peri-urban, but not urban residence, was associated with higher odds of concurrent overweight and anemia among children (OR: 1.8; 95% CI; 1.0, 3.2) and of households with an overweight woman and stunted child (1.8; 1.2, 2.7). Examining the components of the double burden, peri-urban women and children, respectively, had higher odds of overweight than rural residents [women (1.5; 1.2, 1.8); children (1.5; 1.0, 2.4)], and children from peri-urban regions had higher odds of stunting (1.5; 1.1, 2.2). Conclusions: Peri-urban, but not urban, residence in Bolivia is associated with a higher risk of the nutritional double burden than rural areas. Understanding how heterogeneous urban environments influence nutrition outcomes could inform integrated policies that simultaneously address both undernutrition and obesity.

Treatment and prevention of malnutrition in Latin America: focus on Chile and Bolivia.

Seven million children under 5 years of age died worldwide in 2011, and one-third had malnutrition. Latin America and Caribbean countries stand out for the notable improvement of their health and nutrition situation, particularly in pregnant women and young children. Nutrition-sensitive interventions such as promoting food security, women's empowerment, social safety nets, clean water, and sanitation, among others, are critical for success. In Bolivia, the program Desnutrición Cero (Malnutrition Zero) was able to reduce mortality from severe malnutrition after 5 years from 25% to less than 5%, based on widespread implementation of the World Health Organization 10-steps protocol for hospitalized care and the application of community management. The Economic Commission for Latin America estimated the cost of malnutrition for Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and the Dominican Republic as US $6,658 million. Approximately 1 million children have dropped out of school because of malnutrition, and as a result, malnourished children have 2 years less schooling, which brings social and economic losses not only to those affected but to society at large. National and international nutrition and food programs developed over the past 50 years have been implemented as integral components of broader strategies of primary healthcare and education, oriented toward preventing deaths and improving the quality of life of low-socioeconomic-status groups. Treating hundreds or thousands of affected children will not solve the global public health problem of malnutrition. Access to adequate amounts of quality foods represents a basic human right and is a necessary precondition for health. In turn, good nutrition and health are prerequisites for human, social, and economic development.

Multi-sectoral interventions for healthy growth.

The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.

Identifying cultural representations of families and the health team to improve the management of severe malnutrition in childhood.

Severe childhood malnutrition is no longer a priority in Latin America, but mortality of hospitalized malnourished children continues to be high, especially in Bolivia. The objective of the present study was to identify cultural representations in mothers and in health personnel that might influence the relationship between the family and the provider's health care services, thus affecting the treatment of malnourished children. We applied a flexible qualitative model of cases and controls (mothers or caregivers of both under- and well-nourished children), and in addition, health personnel. Results were analyzed following semiotics of statements. Mothers and health professionals based their cultural representations on different conceptions of health. The mothers' mindset indicated that traditional Andean medicine and public health systems are complementary and not contradictory. Conversely, health personnel expressed a univocal vision, accepting only biomedicine. Furthermore, they also expressed a negative attitude toward mothers of severely malnourished children. Results should be considered to improve ongoing local health programs.

Geography and culture matter for malnutrition in Bolivia.

The prevalence of health problems and malnutrition in Bolivia is exceptionally high, even in comparison to other underdeveloped countries. This study analyzes the relationship between a two measures of child health--height-for-age and weight-for-age z-scores--and a set of physical and cultural determinants of child nutrition, including mother's characteristics, household assets and access to public services. The ultimate aim is to identify the most important determinants of child health and to measure the relative impact of each factor on the height and weight z-scores. A sequential strategy was adopted in order to estimate a two-equation linear model with correlated error terms. A major finding points to geographical and cultural variables as main causes of nutritional status and highlights the role of mother's anthropometrical characteristics. This study uses data on over 3000 children gathered from a Demographic and Health Survey (DHS).

Política Andina de prevención y tratamiento de la desnutrición en menores de cinco años / Andean policy of prevention and treatment of malnutrition in under five years

La Política Andina de Prevención y Tratamiento de la Desnutrición en Menores de Cinco Años, pretende ser una herramienta que brinde líneas de acciones concretas y coherentes que conduzcan a la erradicación de la desnutrición en los países de la región,así como consolidar los avances alcanzados y profundizarlos en el marco del cumplimiento de las metas internacionales. Está enmarcada en los enfoques de derechos humanos, de determinantes sociales de la salud y de reducción de brechas de desigualdad, de interculturalidad, intersectorialidad, de género y participativo. Comprende cinco líneas estratégicas: 1. Promover el desarrollo de entornos favorables e intervenciones sensibles a la nutrición para la prevención de la desnutrición crónica y aguda en menores de cinco años con énfasis en los primeros 1000 días. 2. Fomentar acciones orientadas al tratamiento de la desnutrición aguda moderada y severa en menores de cinco años. 3. Fortalecer las prácticas de alimentación y nutrición, higiene y suplementación con micronutrientes para la reducción de la prevalencia de la desnutrición y anemia en la niñez. 4. Fortalecer los sistemas de seguimiento, monitoreo y evaluación para la toma de decisiones, relacionados con el estado nutricional de la niñez, sus causas y consecuencias. 5. Promover la realización de estudios pertinentes (investigaciones operativas) que provean evidencia sobre modelos intersectoriales eficaces y eficientes implementados en contextos diferentes.

Monstruos siameses.Presentación de un caso / Siamese Twins Monsters. Presentation of case

Se presenta el caso de una monstruosidad fetal diagnosticado por ecografía como fetos unidos toracópagosen el Hospital "Orlando Pantoja" del municipio Contramaestre, provincia de Santiago de Cuba. Se expone un resumen de la historia clínica y el estudio necrópsico, así como una breve revisión sobre el origen de esta malformación, que constituye una rareza médica

Modulo de estandarización manejo correcto de diarrea: guía para el facilitador / sss

Para enfrentar los desafios que surgen por causa de la enfermedad diarreíca, se ofrece el presente módulo con el fin de capacitar y estandarizar el manejo correcto de la diarrea de cualquier etiología

Modulo de estandarización manejo correcto de diarrea: guía para el facilitador / sss

Para enfrentar los desafios que surgen por causa de la enfermedad diarreíca, se ofrece el presente módulo con el fin de capacitar y estandarizar el manejo correcto de la diarrea de cualquier etiología

Crecimiento durante los primeros seis meses de vida en ninos con lactancia materna exclusiva / Growth during the first 6 monts of live in child with breast feeding

Se realizo un estudio prospectivo a nivel nacional para determinar las curvas de crecimiento de ninos alimentados con leche materna en forma exclusiva hasta los seis meses de vida. Los resultados indican un crecimiento adecuado con lactancia materna exclusiva. Aunque el numero estudiado es pequeno, es de mucho valor ya que ahora contamos con datos propios que serviran como referencia a futuros estudios que se lleven a cabo en nuestro medio. El estudio refuerza las recomendaciones mundiales, que indican la importancia y ventajas de la alimentacion materna en forma exclusiva durante los seis primeros meses de vida.

Investigación del conocimiento, actitudes y prácticas de las madres hacia la diarrea y su tratamieanto en el área rural de Bolivia / Research of the knowledge, attitudes, and practices of the mothers toward diarrhea and her treatment in the rural defendant of Bolivia

La presente investigación fue realizada mediante cuestionarios a mujeres pertenecientes a Centros de Madres del Programa Materno Infantil de Caritas Boliviana en el área rural de los departamentos de La Paz y Oruro. La información obtenida se refiere a conocimientos y el manejo de casos de diarrea en sus propios niños en el pasado más inmediato

Investigación del conocimiento, actitudes y prácticas de las madres hacia la diarrea y su tratamieanto en el área rural de Bolivia / Research of the knowledge, attitudes, and practices of the mothers toward diarrhea and her treatment in the rural defendant of Bolivia

La presente investigación fue realizada mediante cuestionarios a mujeres pertenecientes a Centros de Madres del Programa Materno Infantil de Caritas Boliviana en el área rural de los departamentos de La Paz y Oruro. La información obtenida se refiere a conocimientos y el manejo de casos de diarrea en sus propios niños en el pasado más inmediato

Investigación del conocimiento, actividades y prácticas de las madres hacia la diarrea y su tratamiento en el area rural

Introducción. Objetivos. Metodología. Selección de la muestra. Análisis de la investigación. Discusión. Apendices

Crisis económica en Bolivia y su impacto en las condiciones de vida de los niños / sss

Trata sobre el impacto de la economía boliviana sobre la población, especialmente en los niños, quienes deben padecer de cerca las carencias de vida. es decir los ingresos económicos en los hogares bolivianos no cubren todas sus necesidades, por tal razón deben racionalizar los pocos alimentos que poseen

La Crisis economica en Bolivia y su impacto en las condiciones de vida de los ninos / s

Caracteristicas generales y el estado de desarrollo de Bolivia. La crisis economica. Los efectos especificos de la crisis en la condicion de vida de los ninos. Resumen, conclusiones, perspectivas y sugerencias para el futuro. Indice de cuadros