Case management by community health workers of children with acute respiratory infections: implications for national ARI control programme.

Health worker performance in the management of children with acute respiratory infections (ARI) was assessed in two local government areas (LGAs) in Nigeria. The data derived were utilized to identify training needs. Survey instruments included an inventory list for ARI-related equipment and supplies, observation checklists for children presenting to the health worker with ARI symptoms, a questionnaire for exist interviews with mothers, and a supervisor performance checklist. One hundred and twenty-three health workers in Ife Central LGA and 50 in Ojo were observed at selected public health facilities. Most health workers took a good general history, but specific ARI-related history and physical examination were frequently omitted. Symptomatic diagnosis and treatment were common. Drugs most commonly prescribed for treatment of ARI were chloroquine, paracetamol and antibiotics. Essential drugs and supplies for ARI management were not available in some facilities. Communication with mothers was generally unsatisfactory and instruction on home management incomplete. Many of the health workers had not attended a continuing education programme in the previous two years and supervision which could have provided on-the-spot training was irregular. Improvements in ARI case management will require attention to policy, logistics, training (including in-service education) and supervision. The possible role of an integrated approach to the management of the sick child in improving the quality of health worker performance is discussed.

PIP: The authors assessed the performance of 123 health workers in Ife Central local government area (LGA) and 50 in Ojo LGA in managing children with acute respiratory infections (ARI) with the goal of deriving information useful in the development of a national ARI control program. Health workers were observed at nineteen public health facilities in Ife Central LGA and in fourteen in Ojo LGA. Most health workers took good general histories, but specific ARI-related history and physical examination were frequently omitted. ARI was commonly treated on the basis of symptomatic diagnosis. Chloroquine, paracetamol, and antibiotics were most commonly prescribed to treat ARI, although essential drugs and supplies for ARI management were unavailable in some facilities. Communication with mothers was generally unsatisfactory and instruction on home management incomplete. Many of the health workers had not attended a continuing education program in the previous two years, while supervision was irregular. Attention to policy, logistics, training, and supervision will be required to improve ARI case management in Nigeria. The authors discuss the potential role of an integrated approach to managing sick children.

Hepatic function tests in children with sickle cell anaemia during vaso occlusive crisis.

Thirty children with sickle cell anaemia had their serum alanine aminotransferase, alkaline phosphatase, total protein, albumin and bilirubin, assayed during vaso-occlusive crisis and at recovery. Alanine aminotransferase, alkaline phosphatase and bilirubin levels were significantly higher during crisis than at recovery, (p < 0.005) especially in the young patient. However, the total protein and albumin levels were not significantly different in crisis and at recovery. A transient hepatic functional derangement during vaso-occlusive crisis is a probable explanation for the reported changes.

Acute respiratory infections in Nigerian children: prospective cohort study of incidence and case management.

A community-based prospective surveillance and case management study of acute respiratory infection (ARI) in children aged 2-60 months of age was carried out over a 12-month period in Pakata, a semi-urban community in Ilorin, Kwara State, Nigeria. A cohort of 481 children was followed by trained community health assistants with thrice weekly home visits to record all symptoms and signs of ARI, and institute treatment based on WHO recommendations. There were three episodes of mild, moderate, or severe ARI per child per year, including 1.3 pneumonia episodes per child per year. The peak of infection corresponded to the rainy season (July-November), and a smaller peak to the dry season (February-April). Most of the health worker decisions were considered appropriate, although there was a tendency toward over-treatment with antibiotic drugs. An effective referral system was established from the community to a tertiary centre. There were no ARI-related deaths during the study period. These data indicate that a system of case management using trained community health workers can improve case management of ARI and may prevent severe ARI-related disease and deaths.

Outcome of referred neonates weighing less than 2500 g.

The pattern of morbidity and mortality of 103 neonates weighing less than 2500 g referred to a Nigerian University Teaching Hospital over a period of 30 months (March 1989-August 1991) was studied. Fifty seven (55.3%) weighted less than 1500 g, 80 (77.7%) were preterm while 23 (22.3%) were term, small for gestation. Sepsis, hypothermia, respiratory distress syndrome and birth asphyxia were the commonest problems encountered. These were also the predominant associated causes of death. The corrected mortality rate was 65.3%, the rate being higher for babies weighing less than 1500 g (chi 2 = 4.02, p < 0.05) and for small for gestational age babies (chi 2 = 5.17, p < 0.025). The early neonatal problems stemmed from suboptimal conditions of perinatal resuscitation, thermoregulation and transfer. High mortality was also caused by poor state of facilities at the referral centre. Early materno-foetal transfer during preterm labour to hospitals with facilities for optimal perinatal care would reduce morbidity and mortality.

Some environmental risk factors for childhood asthma: a case-control study.

A case-control study of the home environment of 140 asthmatic children and 140 controls (matched for age, sex and socio-economic status) was carried out in two semi-urban Nigerian teaching hospitals. The mean age of the children was 66 months, and the mean monthly family income was US $50.00. The average number of people in a household was seven, with a mean sleeping density of 4.9 persons per sleeping area. There was a strong and significant association between asthma and a damp, mouldy bedroom (OR = 11.2, p < 0.001), household pets (OR = 116.8, p < 0.001), cigarette smoke (OR = 2.1, p < 0.01), mosquito coil (OR = 3.7, p < 0.001), and rodents/cockroaches (OR = 113.7, p < 0.001). There was a curious but unexplained protective effect of indoor biomass smoke (OR = 0.6, p < 0.001), indoor plants (OR = 0.5, p < 0.01), mould growth elsewhere in the home (OR = 0.5, p < 0.01), and cosmetic aerosols (OR = 0.6, p < 0.05). Control of the micro- as well as the macro-environment of the asthmatic child as an adjuvant to drug therapy is discussed.

Bacterial pathogens in malnourished children with pneumonia.

Lung puncture aspirates were obtained from 99 malnourished children aged 9 months to 5 years with pneumonia, in order to identify the causative bacterial agents. Klebsiella species, Staphylococcus aureus and Escherichia coli were identified in 39.4%, 30.3% and 8.8% of aspirates, respectively. Approximately half to two-thirds of the children in each aetiological group had the same organisms isolated in both lung aspirates and blood. The bacterial agents reflected the immunocompromised status of the patients. Isolation of Klebsiella species was associated with age (p < 0.01), and type of malnutrition (p < 0.05); while that of Staphylococcus aureus was only statistically associated with type of malnutrition (p < 0.01). Gentamicin and cloxacillin represent a safe antibiotic regime for pneumonia in children with moderate to severe malnutrition.

Kerosene poisoning in childhood: a 6-year prospective study at the University of Ilorin Teaching Hospital.

In a 6-year prospective study of kerosene poisoning in children admitted to the Department of Paediatrics, University of Ilorin Teaching Hospital (UITH), between January 1982 and December 1987, 109 cases were seen. They were aged 6 months to 9 years, with a male: female ratio of 1.8:1. Majority (79.8%) were below 2 years. Many households (52.3%) stored the agent in familiar beverage or household containers placed on kitchen or bedroom floors, within easy reach of infants and toddlers. Seventy-six (69.7%) cases had home remedies, palm oil being the most common accounting for 55.3%. More than half of the cases (56.9%) presented within 12 hours of the accident due to persistent cough and dyspnoea. Respiratory complications viz pneumonia, pleural effusion and pulmonary oedema were the most common, evident in 67.3% of those who had chest radiographs. Approximately, three quarters (74.3%) of patients with radiologic abnormalities had palm oil alone or in combination with milk as home remedies. Severity of poisoning was influenced by the type of home remedy and the interval between accident and admission (P less than 0.05; P less than 0.01 respectively). Presence of radiological or CNS abnormality or both was associated with a higher morbidity. The only death in the study had complications referable to both systems. Ways of minimizing the risk of kerosene poisoning and its attendant morbidity are discussed.

Weaning practices in Ilorin community, Nigeria.

The paper examines the knowledge, attitude and practice of weaning in 516 mothers in Ilorin community, the capital of Kwara State of Nigeria. Women with a higher level of education and family income breastfed for a shorter period, and tended to wean earlier than the illiterate and low income group (p less than 0.05). Two hundred and twenty-eight mothers (44.2%) had commenced weaning by 3 months of age while 433 (83.9%) had done so by 6 months. Hunger, indicated by crying after a feed or demanding more frequent feeds, was the commonest reason for weaning (36.2%). Pap (maize or guineacorn gruel), an energy-sparse food remained the major weaning food irrespective of socio-economic characteristics. Fortification of pap was positively influenced by a high family income and education. Diarrhoea, associated with bottlefeeding or cow-pea diet, was the major cause of morbidity reported during weaning (55.8%). Ways of improving child health during the weaning period are suggested.

Mothers as agents of growth monitoring: implications for widespread community growth monitoring.

A total of 518 mothers, aged 18 to 45 years, were interviewed to study a variety of indicators and local standards used to assess the course of their children's growth. The features most frequently recognized by mothers as indicators of growth were related to maternal age, parity and educational status. The younger mothers (age less than or equal to 30 years and parity less than or equal to 3) used weight and health frequently to assess growth, while the older mothers recognized growth by comparison with other children and changes in mood (P less than 0.01). The latter two indicators were found to be a function of maternal experience. Unlike age and parity, age and education seemed to have no joint association with the various responses. We conclude and recommend that weight, health and stages of development are reliable and acceptable indices for community growth monitoring.

Age and anthropometric status of Nigerian girls at puberty: implication for the introduction of sex education into secondary schools.

Age, height and weight at various stages of pubertal development were assessed in a cross-sectional survey of 1054 schoolgirls living in Ilorin, Nigeria. The first sign of puberty; breast bud and pubic hair development appeared at mean age (year) 12.7 +/- 1.0 and 12.8 +/- 0.9 respectively, and reached full maturational stage at mean age (year) 14.7 +/- 1.3 and 14.4 +/- 1.4 respectively. The mean age, height and weight at which the intermediate stages are reached were given. Cumulative proportion of girls that have attained menarche at each pubertal stage were derived. Median age of menarche calculated by status quo method was 13.6 years. In general, about 50% of girls in each stage of pubic hair development were at corresponding stage of breast development. Only about 75% of girls have full axillary hair growth at Tanner stage--5 of breast and pubic hair development, Longitudinal data to assess growth spurt and peak height velocity are suggested. Introduction of sex education into secondary school classes represented by the pubertal age group is advocated.

Effect of diarrhoea on dietary intake by infants and young children in rural villages of Kwara State, Nigeria.

Community-based, quantitative studies of dietary intake by 5- to 28-months-old Nigerian children were conducted during episodes of diarrhoea and subsequent convalescent and healthy periods. Energy intakes during diarrhoea (85.3 kcal/kg per d) were slightly lower than during health (95.9 kcal/kg per d, P less than 0.05), using paired analysis of intra-individual differences. When intake was disaggregated by food source, no differences by illness status were found in energy intake from breast milk or liquid pap. There were no differences in frequency or duration of breastfeeding by illness status, but pap was provided more frequently and in smaller amounts during illness. Energy intake from other foods, including solids, was greater during health than diarrhoea (P less than 0.05) with an increase in number of servings per day. There was no evidence of caretakers either withholding food during illness or providing extra food during the convalescent phase. The magnitude of illness-associated differences in these children's daily intake was small relative to the deficit in their intakes, even on healthy days, when compared to the amounts recommended for this age group.

Community awareness and utilization of growth chart in a semi-urban Nigerian community.

Five hundred and eighteen mothers resident in Adeta, Sawmill and Baboko Communities of Ilorin Local Government Area of Kwara State, Nigeria, were interviewed to assess their knowledge, utilization, and understanding of the growth chart. Five health facilities in the communities studied were visited to assess the availability, utilization and understanding of growth charts by health workers. Over half (53.7%) of the mothers interviewed have heard about growth charts. The level of awareness was significantly influenced by maternal age, educational status and parity (PLO.OS). Of those who have heard about growth chart, only 155 (55.8%) have it, and 150 of these (96.8%) use it regularly. One hundred and seventy four (33.6%) of all mothers, but 62.6% of those who have heard about the chart demonstrated an understanding of the markings on it. One hundred and sixteen mothers found the growth chart useful for immunization record, nutrition advice, clinic appointment dates, and assessment of developmental milestones. Two of the five health facilities visited had, and used growth charts. The health workers, however, demonstrated a clear understanding of weighing, plotting, and interpretation of the chart, and gave appropriate advice to mothers. Ways of improving growth monitoring in the community using the growth chart are suggested.

PIP: 518 mothers residing in Adeta, Sawmill and Baboko communities of Ilorin local government areas of Kwara State, Nigeria were interviewed to assess their knowledge, utilization and understanding of the growth chart. 5 health facilities in the communities studied were visited to assess the availability, utilization and understanding of growth charts by health workers. Over half (53.7%) of the mothers interviewed had heard about growth charts. The level of awareness was significantly influenced by maternal age, educational status and parity (PLO.OS). Of those who had heard about growth charts, only 155 (55.8%) have it, and 150 of the these (96.8%) use it regularly. 174 (33.6%) of all mothers, but 62.6% of those who had heard about the chart demonstrated an understanding of the markings on it. 116 mothers found the growth chart useful for immunization record, nutrition advice, clinic appointment dates, and assessment of development milestones. However, growth charts do not have a wide coverage in the Ilorin Community. Only 2 of the 5 health facilities visited had, and used growth charts; the health workers did demonstrate and understanding of the chart and gone appropriate advice to mothers. The growth charts need to be introduced alongside of mothers own methods of assessment of physical, psychological and emotional factors. What is needed is a joint approach to child growth monitoring which combines the observations, coupled with measurements made by both mothers and health workers. In discussing a child's progress with the mother, health workers need to view the child through the mother's eyes and place greater emphasis on questions of behavior, activity level, mood changes and other customary indicators that mothers use to monitor their child's well-being.

Clinical predictors of outcome in childhood pneumonia

Three hundred and thirty children admitted to the University Teaching Hospital with a diagnosis of pneumonia were studied prospectively. Various clinical parameters were examined to determine their sensitivity; specificity and ability to predict the outcome of pneumonia in children. Tachypnoea (respiratory rate 40 per minute); age 3 years; duration of illness 3 days before admission; and presence of associated diseases were strong predictors of mortality. Awareness and recognition of these simple clinical criteria at the family and primary health care level will reduce mortality from childhood pneumonia and improve child survival

Measles and childhood mortality in semi-urban Nigeria.

Two hundred and sixty-nine children who presented with measles between April 1983 and March 1986 at the University of Ilorin Teaching Hospital, were studied. The peak age incidence was during the second half of the first year (40.5%). A positive history of measles vaccination was indicated in only 11.5%, and there was no significant difference in the immunization status 18 months pre- and post-Expanded Programme on Immunization (EPI). Respiratory complications accounted for 88.5% of all the complications, and 92.8% of the deaths. Overall mortality was 26%. The majority of deaths (52.9%) occurred in the age group 6-12 months. Lack of vaccination, high vaccination failure rate, early age of contracting the disease, malnutrition, prevalent bacterial infections and a delay in seeking medical attention were the main factors identified as the probable causes of high morbidity and mortality in measles in Ilorin.