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Child malnutrition
154 Midwifery i
LACTATIONAL A M E N O R R H O E A METHOD A group of of international scientists and policy-makers, meeting in Bellagio, have approved the Lactational Amenorrhoea Method (LAM) as a form of family planning for breast-feeding women. The group concluded that the method was both very safe and very effective. For it to work the women must be: amenorrhoeic, within six months after delivery, and fully or nearly fully breast feeding - all three conditions must be fulfilled. Pregnancy is delayed during breast feeding because stimulation by the baby suckling sends a signal to the mother's hypothalamus, which then reduces the secretion of the pituitary hormones needed for ovulation. Breast feeding method is approved by expert panel. Popline 1996 Mar-Apr; 18:3
DEALING W I T H D I A R R H O E A In Africa each child under five probably has about five episodes of diarrhoea per year and 800000 die annually from diarrhoea and its resulting dehydration. Preventing diarrhoea ultimately depends on improving the water supply and sanitation, which is expensive. However, using oral rehydration salts (ORS) or simple home-made fluids, prevention of death from dehydration is straightforward and cheap. Since 1992 the incidence of diarrhoea has been made worse by an epidemic of shigella dysentery. This has been a direct cause of child death and in addition is responsible for 15% of diarrhoea deaths. This form of dysentry is increasingly resistant to first-line drugs. From 1996 some countries will be using the WHO/UNICEF Integrated Management of Childhood Illness which aims to reduce mortality further by ensuring that children receive co-ordinated treatment and preventive action for their needs. Since 1980 WHO's Control of Diarrhoeal Diseases (CDD) Programme has focused much of its research on the management of diarrhoea and in particular on developing improved ORS and the assessment of the usefulness of antibiotics. The early standard ORS, based on sodium bicarbonate, were challenged in the mid1980s by alternatives containing trisodium citrate and these were adopted as the recommended formulae in 1985. In the past doctors have advised that the feeding of solids should be suspended, or at least restricted, during diarrhoea attacks, but
because so many victims had had poor diets when newly born the CDD Programme thought it important to demonstrate that this might not after all be necessary. A study in Burma showed that there were lower stool losses from children who continued to breast feed, so the 1986-1987 report concluded: 'There is now compelling evidence that the adverse nutritional consequences of acute diarrhoea can be minimised or prevented by continuing to feed a nutritionally balanced diet, including breast milk for nursing infants, during diarrhoea episodes'. Various drugs have been tested over the years, especially those which may have affected intestinal secretion and absorption. Pharmaceutical and traditional remedies for acute watery diarrhoea were studied but none were considered sufficiently efficacious or free of adverse side-effects. A 1990 WHO review concluded that no drugs should be used in the routine management of childhood diarrhoea, and in fact some were not only harmful but potentially fatal. Antibiotics should be restricted to severe cases of cholera. From 1986-1987 the Programme took a more active interest in persistent diarrhoea, redefined as attacks which started as acute but lasted 14 days or more. Previously 21 days had been the accepted minimum duration. Initial studies showed that reducing cows' milk intake in favour of yoghurt was beneficial, and supplying regular (six per day) meals of thick cereal and added oil, with vegetables, pulses, meat or fish as available assured a full energy intake. This has been the basis of current recommendations. Guidelines for the treatment of shigella dysentery were developed during 1994-1995. These emphasised that in particular: -
treatment should include an oral antimicrobial known to be effective against most shigella in the area;
- e f f e c t i v e antimicrobial agents should lead to clinical improvements within two days; - children not improving after two days should be given a different antimicrobial, also effective against most local shigella; -treatment for amoebiasis (metronidazole) should not be given routinely; - all children should be given appropriate fluids, to treat or prevent dehydration, and breast feeding should continue. Diarrhoeal diseases. WHO Factsheet 1996 Mar; (109): 1; and: WHO Division of Diarrhoeal and Acute Respiratory Disease Control. t 994-1995 report. Geneva: WHO, 1996: 9-21.
IODINE DEFICIENCY DISORDERS 'Iodine deficiency remains the single greatest cause of preventable brain damage and mental retardation worldwide' (WHO 1996). In 1990 WHO estimated that 1570 million people were at risk of iodine deficiency disorders ODD), and that in 1995 750 million people had goitre. Even a marginal reduction of iodine intake during pregnancy can reduce a child's mental development by 10%. WHO's goal for the year 2000 is that at least 90% of edible salt, including that used for animals, be adequately iodised, and some areas, in particular west and central Africa, will need extra support for that to be achieved. Over the last five years some 1500 million more people have been consuming iodised salt at a cost of about four US cents per beneficiary, and by February 1996 57% of the population of 83 identified developing countries were receiving an adequate iodine intake; but because iodisation has not been targeted it is not possible to say how many potential IDD victims have been saved. Where countries have been unable to implement a full iodisation programme iodised oil supplements are being used as a temporary measure. Iodine deficiency disorders. WHO Factsheet 1996 May; (121): 1-3
CHILD M A L N U T R I T I O N In the developing world some 174 million children under five years of age are malnourished and 230 million are stunted. Fifty-four per cent of all deaths of children under five are associated with malnutrition. In south Asia more than half of all young children have protein-energy malnutrition compared with 10% in the western hemisphere. In some south Asian countries and in sub-Saharan Africa there has been an actual increase in the number of malnourished children. By the end of January 1996 98 countries had national plans of action for nutrition and 41 other had them under consideration. Successful programmes incorporate the following elements: good nutritional status of young women before they become mothers, and the improvement of nutrition during pregnancy and lactation; - careful attention to complementary feeding combined with the continued protection, promotion and support of breast feeding; - t h e
International news
-
reference to micronutrient status in any programme to combat malnutrition; - the prevention of nutritional emergencies and the provision of 'safety nets' for the most vulnerable in case the unavoidable happens. Child malnutrition. WHO Factsheet 1996 May; (119): 1-3.
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-
W H O , HIV A N D AIDS Since 1987 W H O ' s Global Programme on AIDS (GPA) has provided support and guidance for AIDS projects in more than 150 countries. Together with five other United Nations agencies WHO set up the new Joint UN Programme on HIV/AIDS (UNAIDS) in 1995 and the new programme formally superseded the old on 1 January 1996. To aid continuity in this area WHO has also set up its Office of HIV/AIDS and Sexually Transmitted Diseases (ASD) with four main objectives: - to ensure a co-ordinated global, regional and national WHO response to STDs and AIDS; to facilitate integration of related activities in the work of WHO through the provision of appropriate support; - to ensure liaison between WHO, UNAIDS and the other co-sponsors, and other UN, and non-UN, organisations; to co-ordinate within WHO, and jointly with UNAIDS and the other co-sponsors the mobilisation of resources for these activities.
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increase the risk of HIV infection by 300-400%, but STD control slows the process; as families become sick the household becomes poorer because of the expenses of care, but support from the extended family and the community reduces the economic impact; there is a significant depletion of the workforce, but more businesses are offering HIV/AIDS prevention programmes to their workers; certain professions are more at risk but intervention programmes have been successful in educating people in safer practices; in urban areas up to 75% of hospital beds may be occupied by AIDS patients, but these patients now play a significant role in educating the rest of the community about the disease. HIV/AIDS epidemiology in sub-Saharan Africa. UNAIDS Fact Sheet, 1996
SLEEPING W I T H MOTHER
-
-
WHO and HIV/AIDS. WHO Factsheet 1996 May; (120): 1-2
HIV / AIDS IN AFRICA The burden of AIDS in many African countries is 100 times heavier than that in industrialised countries, and yet their resources to alleviate it may be several hundred times less. UNAIDS estimates that nearly 13 million adults are living with HIV in subSaharan Africa, some 65% of the world total, and that by 2000 this will have risen to 30-40 million, or 60% of the total. However, in some countries, such as Uganda, the rate of new infections appears to be stable or even decreasing. This indicates that efforts at prevention can be successful. Over 50% of new HIV infections in Africa occnr in women, and women also carry the main burden of caring for family members with the virus. The impact of this epidemic is felt in several ways: - sexually-transmitted diseases (STDs) fuel the epidemic, if untreated they can
In Western societies the practice of parents sleeping with their babies has come to be thought strange, unhealthy and dangerous. It is said that the babies may become too dependent on their parents or risk accidental suffocation. However, this is not supported by human experience worldwide where babies have traditionally slept with, usually, their mothers as a matter of course. The baby receives protection, warmth, emotional reassurance - and breast milk in the right quantities, and also prompt attention if it cries, chokes or has any other needs. Suffocation is only a real danger in situations of poverty and overcrowding, where there may be smoke-filled and under-ventilated rooms. The risk of sudden infant death syndrome (SIDS) from 'co-sleeping' is also greatly exaggerated. If the mother is a smoker then the risk is increased, but research from, for example, Japan where women traditionally sleep with their babies, shows that SIDS rates are among the lowest in the world. Furthermore, research has shown that bed sharing increases breast feeding episodes, reduces crying and leaves the baby spending less time awake. Research has also shown how tightly bound up the mother-baby relationship is and how any degree of separation has adverse consequences. McKenna JJ 1996 Babies need their mothers beside them. World Health 49 (2): 14-15
155
T R A D I T I O N A L MEDICINE The WHO is well aware that some traditional medicines are more beneficial than others and, since 1977, its Traditional Medicine Programme has been involved in examining all aspects of traditional medicine critically and with an open mind. In 1994 WHO was asked to consider the contribution it might make in promoting respect for and maintaining traditional remedies. In developing countries the traditional practitioners still perform most of the medical and other health-related functions. For example, TBAs may conduct up to 95% of all births in rural areas (and up to 70% in the cities). Meanwhile in industrialised countries there is an ever-growing interest in alternative medicine. Medicinal plants and herbs have become big business - in China in 1993 sales of herbal medicines totalled US$2.4 billion and in Japan between 1979 and 1989 sales increased fifteen-fold. There are now 24 WHO Collaborating Centres for Traditional Medicine, eight concerned with acupuncture and the remainder with herbal medicines. Their role is to support WHO in implementing its policies and decisions and have significantly advanced the standardisation of practices and the exchange of information. Government and other national research institutes have also been set up in developing and industrialied countries alike, and there is no doubt that this branch of medicine will make a significant contribution to the achieving of health for all. Zhang X 1996 Traditional medicine and WHO. World Health 49 (2): 4-5
DATES FOR YOUR DIARY The International Confederation of Midwives 25th Triennial Congress This congress will be hosted by" the Integrated Midwives Association of the Philippines Inc at the Philippine International Convention Center, Manila from May 22 to 26, 1999. The Congress theme will be Midwifery and Safe Motherhood: Beyond the Year 2000. For further details please contact: The Secretariat, 25th ICM Triennial Congress, Integrated Midwives Association of the Philippines Inc, Pinaglabanan corner Ejercito Streets, San Juan, Metro Manila, PO Box no SJPO 175346. Fax: +63 2 70 53 35.
LACTATIONAL A M E N O R R H O E A METHOD A group of of international scientists and policy-makers, meeting in Bellagio, have approved the Lactational Amenorrhoea Method (LAM) as a form of family planning for breast-feeding women. The group concluded that the method was both very safe and very effective. For it to work the women must be: amenorrhoeic, within six months after delivery, and fully or nearly fully breast feeding - all three conditions must be fulfilled. Pregnancy is delayed during breast feeding because stimulation by the baby suckling sends a signal to the mother's hypothalamus, which then reduces the secretion of the pituitary hormones needed for ovulation. Breast feeding method is approved by expert panel. Popline 1996 Mar-Apr; 18:3
DEALING W I T H D I A R R H O E A In Africa each child under five probably has about five episodes of diarrhoea per year and 800000 die annually from diarrhoea and its resulting dehydration. Preventing diarrhoea ultimately depends on improving the water supply and sanitation, which is expensive. However, using oral rehydration salts (ORS) or simple home-made fluids, prevention of death from dehydration is straightforward and cheap. Since 1992 the incidence of diarrhoea has been made worse by an epidemic of shigella dysentery. This has been a direct cause of child death and in addition is responsible for 15% of diarrhoea deaths. This form of dysentry is increasingly resistant to first-line drugs. From 1996 some countries will be using the WHO/UNICEF Integrated Management of Childhood Illness which aims to reduce mortality further by ensuring that children receive co-ordinated treatment and preventive action for their needs. Since 1980 WHO's Control of Diarrhoeal Diseases (CDD) Programme has focused much of its research on the management of diarrhoea and in particular on developing improved ORS and the assessment of the usefulness of antibiotics. The early standard ORS, based on sodium bicarbonate, were challenged in the mid1980s by alternatives containing trisodium citrate and these were adopted as the recommended formulae in 1985. In the past doctors have advised that the feeding of solids should be suspended, or at least restricted, during diarrhoea attacks, but
because so many victims had had poor diets when newly born the CDD Programme thought it important to demonstrate that this might not after all be necessary. A study in Burma showed that there were lower stool losses from children who continued to breast feed, so the 1986-1987 report concluded: 'There is now compelling evidence that the adverse nutritional consequences of acute diarrhoea can be minimised or prevented by continuing to feed a nutritionally balanced diet, including breast milk for nursing infants, during diarrhoea episodes'. Various drugs have been tested over the years, especially those which may have affected intestinal secretion and absorption. Pharmaceutical and traditional remedies for acute watery diarrhoea were studied but none were considered sufficiently efficacious or free of adverse side-effects. A 1990 WHO review concluded that no drugs should be used in the routine management of childhood diarrhoea, and in fact some were not only harmful but potentially fatal. Antibiotics should be restricted to severe cases of cholera. From 1986-1987 the Programme took a more active interest in persistent diarrhoea, redefined as attacks which started as acute but lasted 14 days or more. Previously 21 days had been the accepted minimum duration. Initial studies showed that reducing cows' milk intake in favour of yoghurt was beneficial, and supplying regular (six per day) meals of thick cereal and added oil, with vegetables, pulses, meat or fish as available assured a full energy intake. This has been the basis of current recommendations. Guidelines for the treatment of shigella dysentery were developed during 1994-1995. These emphasised that in particular: -
treatment should include an oral antimicrobial known to be effective against most shigella in the area;
- e f f e c t i v e antimicrobial agents should lead to clinical improvements within two days; - children not improving after two days should be given a different antimicrobial, also effective against most local shigella; -treatment for amoebiasis (metronidazole) should not be given routinely; - all children should be given appropriate fluids, to treat or prevent dehydration, and breast feeding should continue. Diarrhoeal diseases. WHO Factsheet 1996 Mar; (109): 1; and: WHO Division of Diarrhoeal and Acute Respiratory Disease Control. t 994-1995 report. Geneva: WHO, 1996: 9-21.
IODINE DEFICIENCY DISORDERS 'Iodine deficiency remains the single greatest cause of preventable brain damage and mental retardation worldwide' (WHO 1996). In 1990 WHO estimated that 1570 million people were at risk of iodine deficiency disorders ODD), and that in 1995 750 million people had goitre. Even a marginal reduction of iodine intake during pregnancy can reduce a child's mental development by 10%. WHO's goal for the year 2000 is that at least 90% of edible salt, including that used for animals, be adequately iodised, and some areas, in particular west and central Africa, will need extra support for that to be achieved. Over the last five years some 1500 million more people have been consuming iodised salt at a cost of about four US cents per beneficiary, and by February 1996 57% of the population of 83 identified developing countries were receiving an adequate iodine intake; but because iodisation has not been targeted it is not possible to say how many potential IDD victims have been saved. Where countries have been unable to implement a full iodisation programme iodised oil supplements are being used as a temporary measure. Iodine deficiency disorders. WHO Factsheet 1996 May; (121): 1-3
CHILD M A L N U T R I T I O N In the developing world some 174 million children under five years of age are malnourished and 230 million are stunted. Fifty-four per cent of all deaths of children under five are associated with malnutrition. In south Asia more than half of all young children have protein-energy malnutrition compared with 10% in the western hemisphere. In some south Asian countries and in sub-Saharan Africa there has been an actual increase in the number of malnourished children. By the end of January 1996 98 countries had national plans of action for nutrition and 41 other had them under consideration. Successful programmes incorporate the following elements: good nutritional status of young women before they become mothers, and the improvement of nutrition during pregnancy and lactation; - careful attention to complementary feeding combined with the continued protection, promotion and support of breast feeding; - t h e
International news
-
reference to micronutrient status in any programme to combat malnutrition; - the prevention of nutritional emergencies and the provision of 'safety nets' for the most vulnerable in case the unavoidable happens. Child malnutrition. WHO Factsheet 1996 May; (119): 1-3.
-
-
W H O , HIV A N D AIDS Since 1987 W H O ' s Global Programme on AIDS (GPA) has provided support and guidance for AIDS projects in more than 150 countries. Together with five other United Nations agencies WHO set up the new Joint UN Programme on HIV/AIDS (UNAIDS) in 1995 and the new programme formally superseded the old on 1 January 1996. To aid continuity in this area WHO has also set up its Office of HIV/AIDS and Sexually Transmitted Diseases (ASD) with four main objectives: - to ensure a co-ordinated global, regional and national WHO response to STDs and AIDS; to facilitate integration of related activities in the work of WHO through the provision of appropriate support; - to ensure liaison between WHO, UNAIDS and the other co-sponsors, and other UN, and non-UN, organisations; to co-ordinate within WHO, and jointly with UNAIDS and the other co-sponsors the mobilisation of resources for these activities.
-
increase the risk of HIV infection by 300-400%, but STD control slows the process; as families become sick the household becomes poorer because of the expenses of care, but support from the extended family and the community reduces the economic impact; there is a significant depletion of the workforce, but more businesses are offering HIV/AIDS prevention programmes to their workers; certain professions are more at risk but intervention programmes have been successful in educating people in safer practices; in urban areas up to 75% of hospital beds may be occupied by AIDS patients, but these patients now play a significant role in educating the rest of the community about the disease. HIV/AIDS epidemiology in sub-Saharan Africa. UNAIDS Fact Sheet, 1996
SLEEPING W I T H MOTHER
-
-
WHO and HIV/AIDS. WHO Factsheet 1996 May; (120): 1-2
HIV / AIDS IN AFRICA The burden of AIDS in many African countries is 100 times heavier than that in industrialised countries, and yet their resources to alleviate it may be several hundred times less. UNAIDS estimates that nearly 13 million adults are living with HIV in subSaharan Africa, some 65% of the world total, and that by 2000 this will have risen to 30-40 million, or 60% of the total. However, in some countries, such as Uganda, the rate of new infections appears to be stable or even decreasing. This indicates that efforts at prevention can be successful. Over 50% of new HIV infections in Africa occnr in women, and women also carry the main burden of caring for family members with the virus. The impact of this epidemic is felt in several ways: - sexually-transmitted diseases (STDs) fuel the epidemic, if untreated they can
In Western societies the practice of parents sleeping with their babies has come to be thought strange, unhealthy and dangerous. It is said that the babies may become too dependent on their parents or risk accidental suffocation. However, this is not supported by human experience worldwide where babies have traditionally slept with, usually, their mothers as a matter of course. The baby receives protection, warmth, emotional reassurance - and breast milk in the right quantities, and also prompt attention if it cries, chokes or has any other needs. Suffocation is only a real danger in situations of poverty and overcrowding, where there may be smoke-filled and under-ventilated rooms. The risk of sudden infant death syndrome (SIDS) from 'co-sleeping' is also greatly exaggerated. If the mother is a smoker then the risk is increased, but research from, for example, Japan where women traditionally sleep with their babies, shows that SIDS rates are among the lowest in the world. Furthermore, research has shown that bed sharing increases breast feeding episodes, reduces crying and leaves the baby spending less time awake. Research has also shown how tightly bound up the mother-baby relationship is and how any degree of separation has adverse consequences. McKenna JJ 1996 Babies need their mothers beside them. World Health 49 (2): 14-15
155
T R A D I T I O N A L MEDICINE The WHO is well aware that some traditional medicines are more beneficial than others and, since 1977, its Traditional Medicine Programme has been involved in examining all aspects of traditional medicine critically and with an open mind. In 1994 WHO was asked to consider the contribution it might make in promoting respect for and maintaining traditional remedies. In developing countries the traditional practitioners still perform most of the medical and other health-related functions. For example, TBAs may conduct up to 95% of all births in rural areas (and up to 70% in the cities). Meanwhile in industrialised countries there is an ever-growing interest in alternative medicine. Medicinal plants and herbs have become big business - in China in 1993 sales of herbal medicines totalled US$2.4 billion and in Japan between 1979 and 1989 sales increased fifteen-fold. There are now 24 WHO Collaborating Centres for Traditional Medicine, eight concerned with acupuncture and the remainder with herbal medicines. Their role is to support WHO in implementing its policies and decisions and have significantly advanced the standardisation of practices and the exchange of information. Government and other national research institutes have also been set up in developing and industrialied countries alike, and there is no doubt that this branch of medicine will make a significant contribution to the achieving of health for all. Zhang X 1996 Traditional medicine and WHO. World Health 49 (2): 4-5
DATES FOR YOUR DIARY The International Confederation of Midwives 25th Triennial Congress This congress will be hosted by" the Integrated Midwives Association of the Philippines Inc at the Philippine International Convention Center, Manila from May 22 to 26, 1999. The Congress theme will be Midwifery and Safe Motherhood: Beyond the Year 2000. For further details please contact: The Secretariat, 25th ICM Triennial Congress, Integrated Midwives Association of the Philippines Inc, Pinaglabanan corner Ejercito Streets, San Juan, Metro Manila, PO Box no SJPO 175346. Fax: +63 2 70 53 35.