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Child Health, Nutrition & Vaccinology - Coggle Diagram
Child Health, Nutrition & Vaccinology
Child health
Under-5
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Global Goals
MDG 4.A Reduce Child Mortality (under-5) by 2/3 (1990-2015)
- Global = Not quite met (from 90:1K to 43:1K; expected 30:1K)
- Achieved = Americas, Europe, Western Pacific
- Not achieved = Africa, SEA, Eastern Med
MDGs on child (incl. repro health) NOT ACHIEVED
- MDG5.A: reduce the maternal mortality ratio by 75% (from 380:100K to 210:100K; epxected 95:100K)
- MDG5.B: achieve uni access to repro health
- Pregnant women receiving adequate antenatal care visits )from 35% in dvlpg regions, increased to 52%)
- Women aged 15-49 in marriage/union using contra (from 55% in dvlpg countries, increased to 64%).
New Strategy after 2015: Global Strategy for Women's, Children's & Adolescents' Health (2016-2030)
- 1990 = 12.6M under-5 deaths
- 2015 = 5.8M
- MDG target (2015) = 4.2M
- SDG Target (2030) = 2.8M
SDG3.2. Newborn & child mortality = end preventable deaths of newborns & children under-5, with all countries
- Neonatal mortality <12:1k
- Under-5 mortality rate <25:1K
:!: If met or exceeded = 8M under-5 deaths would be averted!!
Current trend:
- +60 countries will not meet neonatal
- +50 countries will not meet under-5
Causes of death
Causes of death (2015)
- Prematurity (16%)
- Intrapartum-related complications - incl birth asphyxia (11%)
- Neonatal sepsis (7%)
- Congenital anomalies (5%)
- Pneumonia (3%)
- Neonatal tetanus (1%)
- Other (3%)
- Post-neonatal (1-59 months [5y])
- Pneumonia (13%)
- Other grp 1 conditions (10%)
- Diarrhoea (9%)
- Congenital anomalies & other NCDs (8%)
- Injuries (6%)
- Malaria (5%)
- Measles (1%)
- HIV/AIDS (1%)
--> Nutritional deficiencies not mentioned
Under-5 deaths
- Most are caused by readily preventable or treatable diseases w/ proven cost-effective interventions
- Infectious diseases & neonatal complications responsible for majority
Children aged 5-14 = mainly injuries & NCDs
Leading causes of death in SSA
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Responses
Overall decreasing mortality BUT decline has been slow, stagnating or reversing in many countries (esp SSA)
- Vaccines
- Preventative measures = safe water & sani
- Avoid exposures = in & outdoor pollution
- Better housing
- Better nutrition
- Curative measures (incl specific, syndromic or symptomatic treatment):
- Anti-parasitic drugs (e.g. antimalarials)
- Antiobiotics (e.g. Amoxicillin)
- Oral rehydration solution (ORS)
Curative measures - Syndromic approaches:green_book: Integrated Mngt of Childhood Illness (IMCI) prog
* Aim = reduce mortality from dehydration & bacterial infections
- Pneumonia aetiology =
- Based on lung aspiration studies from PNG, Malawi & Gambia
- Key symptom of respiratory distress = tachypnoea
- Distinguish severe & very severe penumonia
- Initial studies = achieved mortality reduction
- Limitations pneumonia aetiology =
- Variable (region-specific)
- Changing w/ expanded immunisation roll-out
- Consequences
- Encouraged gross overuse of antibiotics
- Absence of stewardship = increased resistance
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Necessity for effective, accessible & prompt treatment of pneumonia, diarrhoea & malaria
- Delivery of health services often weakest where needs are greatest
- Low coverage of most needed interventions = significant unmet need for treatment
- 39% receive correct diarroeal treatment
- 30% w/ suspected penumonia receive antibiotics
- <20% w/ fever in SSA received malaria testing
- Poor & disadvantaged children w/out access to facility-based case mngt = at even greater risk
Diarrhoea treatment & control
- ORS
- Ensure pur drinking warer & sanitation
Under-5 mortality trends
+100M children savec since 1990 = due to better newborn care practices & vaccines!
- 1990 = 85:1k
- 2016 = 38:1k
- 2030 = 22:1k
Malnutrition
How?
Typical diet in rural LICs
--> Associated to "poorer life"
Food items
- Starch-rich staple (carbohydrates)
- Maize, rice, sorghum, etc.
- Tubers (Cassava)
- Lentils, beans
- Little veg & fruits
- Rarely animal foods
- Diet qual & nutri status
- Energy deficiency
- Microutrient deficiences
- Vits A, B, C, E
- Minerals - Iron, zinc, phosporus
--> Deficiencies in Vit A & zinc = deaths
--> Deficiencies in iodine & iron + stunting = children don't reach dvlpt potential
Measuring Hum Body Comp
- Nutri Anthropometry (study of body measurements)
- Mid Upper-Arm Circumf (MUAC)
--> Easy to use; predicts mortality (if under 115mm increased risk of mortality); little change w/ age
- Triceps Skin Fold (TSF) = measure arm-fat area
- Body Compo
- Air-displacement plethysmography (PEA POD) = body comp tracking system
- Deuterium duution technique = dynrometry / total body water
What?
Terminology of Malnutrition
- Undernutrition (3.1M deaths / year; 45% of all child deaths in 2011)
- Micronutrient deficiencies
- Growth faltering
- Stunting
:globe_with_meridians: Declining (1990 = 253M; 2015 = 153M; 2025 = 127M / goal = 100M) BUT increasing in Af
- Wasting (acute malnutrition)
- Overnutrition
- Energy -> Obesity
--> Before Lancet Maternal & child undernutrition article (2008) = NO MENTION of overweight / obesity
:globe_with_meridians: Increasing globally (1990 = 27M; 2015 = 47M; 2025 = 63M)
:warning:Nutritional Transition (NT)
- Micronutrients -> Toxicity
--> To assess growth indicators (weight, length, height, age) must compare to standard pop (Z-score) through the "normal curve" distri[[Z-score is a numerical measurement that describes a value's relationship to the mean of a group of values]]
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Stunting (shortness) = low height-for-age (HAZ)
- 25% of world chidlren
- Widespread chronic condition (not acute) = becomes shorter over time BUT not a med emergency
- Relunctancy / little policy to offer services
- Often removed from progs (less treatment, more prevention)
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Wasting (thinness / acute malnut) = low weight-for-height (WHZ)
- 8% of world children (1M dying)
- Acute condition = rapid weight decrease (less common)
Causes
Outcome depends on changes in food & nutrition sec due to season, emergencies, intercurrent diseases, etc.
:warning:Consequences
- Low muscle mass = low work capacity = low salary
- Low dvlpt = low educ, intellect & cognitive functions
- Low immunity / infections = Increased chronic diseases infections
--> Not dying directly from malnutrition BUT serves to weaken the children & accentuate other disease symptoms
Complex relationship b/w the 2
- For long considered seperately in terms of causes, effects & treatment
- New evidence of synergestic interaction = stunting contributes to mortality risk of wasting
--> Stunting as a biological response to previous wasting
:!!:Treatment
= should address both jointly & scale-up interventions during "window of opp" (pregnancy + first 1,000 days / 2-24 months / 2 years of life)
- Prevention of low-birth-weight (LBW)
- Appropriate infant feeding practices
3 risks of reduced growth during "window of opp"
- Inadequate maternal & fetal scores = mother pregnant w/ already low nutri stores (maybe stunted herself) & can't support nutri stores for the child
- Inadequate complementary diet (giving too early) = recomms of exclusive breastfeeding 6 months (in reality, water or tea given in few weeks) = impairs baby's gut & leads to Envtl Enteric Dysfunction (EED) [reduced absorption - flat vilil + increased permeability causing intestinal & systemic inflammation]
- Infections
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Severe acute malnutrition (SAM)
widespread but neglected
--> 19M
- Def=
- Very low WHZ
- MUAC <110-115mm
--> Discussion to use simpler methods to detect = only MUAC
- Visible:
- Severe wasting
- Presence of nutritional oedema (Marasmus OR Kwashiorkor)
- Marasmus (simple wasting) = loss of fat & lack of energy (type 2 nutrients)
- Kwashiorkor (oedematous malnutrition = complex, acute + infections (hair & skin changes); unknown source (maybe type 1 nutrients)
--> FALSE ASSUMP = proteni deficiency (reality mortality decrease w/ low protein diet)
--> Also seen in HICs
Dietary Treatment:
- High VS low protein diets:
- High = pos wight change, then neg
- Low = first neg then pos (must first lose oedema then gain lean mass)
- Not about dehydration BUT nutri deciciencies
- Stop iv fluids & iron (may be harmful bc NA-K pumps impaired - High NA + Low K)
- K & Mg suppls
- Antibiotics
- Ready to use therapeutic foods (RUTF) = high energy density + no water (no bacterial growth)
:warning:--> Dramatically improved outcomes BUT increases survival NOT linear growth & cognition
==> Need or early intervention to ensure catch-up of growth & cognition + cheaoer, better prdts for treatment
- Facility-based mngt
- No guidelines for decades
- Then treated w/ high-energy milks = effective BUT long hospitalization (risk of cross-infection; high opp-cost for family; low coverage...)
- F75 + F100 = locally prepared skimmed milk powder, sugar, veg oil & vit/min mix
'+'
- *RUTF
--> Discharge criteria = reduced oedema; good appetite (w/ acceptable intake of RUTF)
THEN PASSED ON TO
- Comm-based mngt = RUTF & basic med care
--> Discharge criteria = 15-20% weight gain
--> Why only provide small amount of energy initially?
Reefeeding syndrome (refeeding induced hypophosphataemia -
- Intercellular phosphorus (P, type 2 nutrient) low during starvation
- Sudden intake of energy = multi organ failure & death
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Moderate Acute Malnutrition (MAM)
--> 36M
- WHZ = 3
- MUAC > 115 mm
- No oedema
Treatment
- Given nothing or inadequate corn-soy-blends
- MUST improve food now!
- Treat Food Trial (MSF, WHO, WFP) = to devlp cost-effective = improved foods gained fat-free mass
- Magnus Trial = stunted children given adequate amount of nutrients = gained fat-free mass w/ LNS protein source (high qual soy, half price of milk)
--> No effects of milk
The role of the gut (immune system) & microbiom in malnutrition - EED
Despite high-qual suppls, chidlren continue to grow poorly
- Cause = poor diet & unhygenic env
- Nutri defi (zinc, cobalamin, vit A...
- Pathogens (bacteria, virus, fungi, protozoa, heminths)
- Food-born mycotoxins
- Air pollution from indoor cooking
- SAM = children have an immature microbiota
- Outcomes of treatment
- Effectively increase weight gain / survival
- Fail to recover linear growth, cogn vlpt & immunity
--> Given outcomes of treatment, is maturation of the gut microbiota key to functional recobery? Is it possible to id foods that increase growth-promoting bacteria? For prevention or treatment? Give capsules of such bateria?
Why?
Conceptual framework w/ SDHs
:!:==> Childhood undernutrition
- Basic conditions (red)
- Pol, cult, rel, econ, social systems
- Res = envt, techno, people
- Underlying (blue)
- Food / nutrition insec (Access to prod/processing methods + fortified foods + supplements)
- Inadequate care (knowledge of health, nutrition, household Y, time & res)
- Inadequate health services (immun, drug, vector control, WASH)
- Immediate (green)
- Inadequate dietary intake
- Infectious diseases
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