Activity 2: Child malnutrition

PI: Dr. Tahmeed Ahmed
 
Child malnutrition: global scenario

About 70 million children are currently suffering from severe malnutrition in developing countries. Although the prevalence of child malnutrition is decreasing in Asia, countries in South Asia still have both the highest rates of malnutrition and the largest numbers of malnourished children. Indeed, prevalence rates of malnutrition in India, Bangladesh, Afghanistan, and Pakistan are much higher (38 to 51 percent) than those in Sub-Saharan Africa (26 percent).The consequences of malnutrition are manifold – increased susceptibility and incidence of infections, impaired mental development, increased case fatality, and a huge loss on national productivity. There is, therefore, an urgent need for reducing prevalence of protein-energy malnutrition, for combating the rampant micronutrient malnutrition, and for reducing the case fatality of children affected by severe malnutrition. How these can be done is the question faced by countries in Asia and Africa which bear most of the burden of childhood malnutrition and are also heavily constrained.   
 
Child malnutrition in Bangladesh

Bangladesh, however, is one of the few countries that shows a trend in improvement of nutritional status of under-two children, and indeed, toward achieving the non-income poverty (malnutrition) target of Millennium Development Goal 1. Over the last two decades there has been an almost 20 percentage point reduction in prevalence of stunting and underweight among under-five children. Despite the good news, prevalence of underweight in Bangladesh is almost double that in Sub-Saharan Africa. The prevalence of stunting (height for age <-2 SD) among 6-23 months old children as observed in the baseline survey of the National Nutrition Programme conducted by ICDDR,B in 2004-2005 was 42%. Almost 50% of children in this age group suffered from underweight (weight for age <-2 SD) while 16% children were wasted (weight for height <-2 SD). Large-scale nutrition programs in Bangladesh focusing on behavior change have been successful in reducing malnutrition rates. Although how much of the reduction in malnutrition is due to the effect of the nutrition interventions or due to contextual factors is not clear.
 
The WHO guidelines for management of severe malnutrition are effective in reducing case fatality among children with severe malnutrition but getting them to scale is important for achieving MDG 4 as there are a quarter million severely wasted children in the country. Although child vitamin A supplementation coverage is satisfactory, there is no such program for controlling anemia in children. Iodine deficiency, despite universal salt iodization, is a substantial problem. Zinc deficiency is also a major problem. Large-scale efforts within the context of the Nutrition sub-sector of the Health, Nutrition Population Sector Program of the Government of Bangladesh are warranted to control these major micronutrient disorders so that there is an impact on child malnutrition in the country.    
 
How can ICDDR,B contribute to alleviate the problem?

There is no single solution to the problem. However, development of skilled human resources is a pre-requisite for alleviating the problem. ICDDR,B has already organized training courses on a number of important nutrition issues for staff of different medical college hospitals. One such issue is the management of childhood malnutrition. In 1996, researchers in ICDDR,B developed a protocolized management of malnutrition, which when implemented, could potentially reduce child mortality due to malnutrition by almost 50%. Later the protocol was merged with recommendation of WHO and UNICEF and is now being implemented worldwide. Research is essential for improving nutrition services in the country. Members of the Nutrition Programme of ICDDR,B facilitate training courses on research methods for participants from different medical colleges and the Bangladesh College of Physicians and Surgeons. Nutrition scientists of the Centre work with faculty members of government institutes in conducting world-class research on nutrition. As a member of the Nutrition Task Group of the MOHFW, the Head of Nutrition Programme of the Centre assists the Ministry in formulating and modifying nutrition policy.   
Through the IHP funded activity we were able to accomplish the following in nutrition:

National guidelines:

Nutrition scientists from the Centre played a key role in formulating the national guidelines on management of severe malnutrition. This was done in collaboration with the Centre for Medical Education, the Institute of Public Health Nutrition, UNICEF and leading Professors of different medical colleges.
 
Service:
 
Nutrition services have been established/ strengthened in Chittagong and Khulna Medical College Hospitals in collaboration with Concern Worldwide. Such services have also been strengthened in Khulna Shishu Hospital. Improved services, including management of children with severe malnutrition, has resulted in reduced case fatality rates of children admitted to the hospitals. Equally important is the fact that these services (e.g. establishment of a Nutrition Block in the hospital) are a means for providing hands-on training for medical and nursing students, doctors and nurses.
 
Research:
 
Two major nutrition research projects have been completed in collaboration with Professors in government medical colleges. Prof Abid Hossain Mollah of Dhaka Medical College is a key investigator of a recently completed research on complimentary feeding of infants. The WHO has identified dosage of vitamin A supplementation as a major research agenda for reducing case fatality among children with severe acute malnutrition (SAM). Scientists from ICDDR,B and Prof CH Rasul of Khulna Medical College have completed a major clinical trial on low and high doses of vitamin A and their effects on case fatality in children with SAM.

Training:

The following training courses have been organized so far by the Nutrition Programme.

• 3-7 April 2005 at ICDDR,B participated by Counselors to work in the Nutrition Blocks of CMCH and KMCH
• 15-19 May 2005 at ICDDR,B participated by six doctors and eight nurses of CMCH and KMCH (14 persons)
• 26 June 7 July 2005 at ICDDR,B participated by FCPS/MD (Paediatrics) students of Dhaka Medical College (12 persons).
• 4 – 15 September 2005 at ICDDR,B participated by FCPS/MD (Paediatrics) students of Dhaka Medical College (15 persons).
• 19-23 February 2006 at ICDDR,B participated by Doctors, Nurses and other Health personnel of BRAC February 2006 (6 persons).
• 27-31 August 2006 at ICDDR,B participated by doctors and nurses of CMCH, KMCH, and Khulna Shishu (children) Hospital (15 persons)
• Facilitation of training course on research methods for postgraduate students, Associate Professors and Professors of Medical Colleges in BCPS, March 2006
• Organized training workshop for doctors and nurses of CMCH, KMCH and Khulna Shishu Hospital in Dhaka, August 2006

Workshops and technical meetings:

• 23-24 February 2005 at KMCH – workshop attended by teaching staff, doctors, nurses, and postgraduate students of Department of Pediatrics, KMCH (35 persons)
• 27 August 2005 at CMCH – workshop attended by teaching staff, doctors, nurses, and postgraduate students of Department of Pediatrics, CMCH (50 persons).
• Facilitated national workshop on management of severe acute malnutrition organized by DGHS, September 2006
• Seminar on severe acute malnutrition in KMCH, September 2006

Support with audiovisual aids for strengthening medical education:

Laptop computers and multimedia were given to Departments of Pediatrics of Chittagong and Khulna Medical College Hospitals.
A total of 197 doctors, nurses, medical students and paramedics received hands-on training on management of SAM in Chittagong Medical College Hospital Nutrition Block.

National collaborating institutions:

• Chittagong Medical College Hospital (CMCH)
• Khulna Medical College Hospital (KMCH)
• Institute of Public Health Nutrition (IPHN)
• Dhaka Medical College Hospital (DMCH)
• Bangabandhu Sheikh Mujibur Rahman Medical University (BSMMU)

Publications:

1. National guidelines on management of severe malnutrition (final draft prepared)
2. Hossain MI, Dodd N, Ahmed T, Jamil KM, et al. Experience in managing severe malnutrition in young children at government tertiary level facility in Bangladesh (submitted for publication)
3. Islam MM, Khatun M, Peerson JM, Ahmed T, Mollah MAH, Dewey KG, Brown KB (2007). Effects of energy density and feeding frequency of complementary foods on total daily energy intake and breast milk consumption by healthy, breastfed children in Bangladesh. 2007 Experimental Biology meeting abstracts [on CDROM], Abstract #239.8
4. Report: A collaborative approach in managing severe malnutrition – an effective strategy for saving children’s lives