Clinical Cases from Resource Limited Settings: Suzinne Pak-Gorstein

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Participants will be able to: recognize importance and identify resources for learning about a country and local 'disease' profile; local/regional guidelines and algorithms appropriate for the specific clinical setting; how to address limitations in clinical resources for diagnosis and management of clinical cases; and understanding health care service structure and personnel/staffing structure.

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  • Clinical Cases from Resource Limited Settings: Suzinne Pak-Gorstein

    1. 2. <ul><li>A 3-year old girl named Marta is brought to you at to rural clinic from a village in Mozambique that is a 2 day walk away. She appears to be weak and frail. She has also been having loose stools for the last 2 weeks. She also has a bad eye 'infection'.  </li></ul><ul><li>What is your approach to diagnosis and management? </li></ul>
    2. 3. <ul><li>How many children under five years of age suffer from severe acute malnutrition? </li></ul><ul><li>What percentage of all child mortality and morbidity would be reduced if malnutrition was eliminated? </li></ul>
    3. 4. Global Burden of Malnutrition <ul><li>~20 million children under five suffer from severe acute malnutrition </li></ul><ul><li>Severe acute malnutrition contributes to 1 million child deaths every year </li></ul><ul><li>An estimated one third of all child mortality and morbidity would be reduced if malnutrition was eliminated </li></ul>Undernutrition underlying cause 53% deaths
    4. 5. The 20 countries with the highest burden of undernutrition
    5. 6. <ul><li>How do we measure under-nutrition? </li></ul>
    6. 7. WHO: Management of Severe Malnutrition, 1999.
    7. 8. <ul><li>So, how severe acute malnutrition be detected in the field without a scale, height board, growth chart, or trained health professional? </li></ul>
    8. 9. Observed relationship between MUAC and child mortality in five studies Briend , BMJ 1986 Mid-Upper Arm Circumference
    9. 10. Identifying Children with Acute Malnutrition If the color is red (MUAC below 11 cm), then the child is severely malnourished and need to immediately be taken to the nearest qualified health worker, health facility or hospital for assessment, treatment and follow up. If the color is yellow (MUAC below 12.5 cm), then the child is moderately malnourished and needs assessment and supplementary foods (additional enriched food). If UNIMIX/CSB is not available, follow the guidelines on good complementary food listed fact sheet “The best foods for children under 5” years Green color (MUAC above 12.5 cm) means that the child is healthy and not malnourished. This child should continue to eat the good foods listed in fact sheet “The best foods for children under 5” Check for Oedema
    10. 11. www.who.int
    11. 12. WHO. Management of severe malnutrition.
    12. 13. Normal SAM ORS R-ORS Na 75, glu 75 Re-So-Mal Rehydration 60 – 80 ml/kg over 4h 5 ml/kg every 30 minutes over 2h then 5 ml/kg/h over next 4-10 hours
    13. 14. <ul><li>ORT preferred </li></ul><ul><ul><li>Recognition of dehydration </li></ul></ul><ul><ul><li>IV hydration only if shock or impending shock </li></ul></ul><ul><li>Selective use of antibiotics ( Dysentery) </li></ul><ul><li>Zinc supplementation </li></ul><ul><ul><li>Given during acute diarrhea episode reduces duration and severity of episode </li></ul></ul><ul><ul><li>Given for 10-14 days reduces incidence of diarrhea in following 2-3 months </li></ul></ul><ul><li>Continued feeding/Breastfeeding </li></ul>
    14. 16. <ul><li>Vitamin A </li></ul><ul><li>Iodine </li></ul><ul><li>Zinc </li></ul><ul><li>Iron, Folate </li></ul>
    15. 17. <ul><li>Vit A Deficiency </li></ul><ul><li>Associated with a 20-24% INCREASE in Risk of death from Diarrhea, Measles, Malaria </li></ul><ul><li>AL Rice et al In: Comparative quantification of health risks, 2004 </li></ul>
    16. 18. MVI Daily, for at least 2 weeks Zinc 2 mg/kg/day Folic acid 5 mg day 1, then 1 mg/day Copper 0.3 mg/kg/day Iron Once gaining weight , 3 mg/kg/day
    17. 19. <ul><li>Energy-dense pastes or biscuits </li></ul><ul><li>Children 6 months and older </li></ul><ul><li>Guided by appetite of the child </li></ul><ul><li>Eaten directly from the container </li></ul><ul><li>Does not contain water </li></ul><ul><ul><li>Bacteria less likely to grow </li></ul></ul><ul><ul><li>No refrigeration required </li></ul></ul><ul><ul><li>Child should be offered safe water to drink at will </li></ul></ul>
    18. 21. <ul><li>Components of Pediatric Primary Health care: </li></ul><ul><ul><li>Growth monitoring </li></ul></ul><ul><ul><li>Vaccination </li></ul></ul><ul><ul><li>Child at Risk Consultation </li></ul></ul><ul><ul><li>“ Sick Child” - IMCI approach </li></ul></ul>
    19. 22. <ul><li>WHO integrated approach to child health </li></ul><ul><li>Aims: reduce death, illness and disability, promote improved growth and development for children <5y </li></ul><ul><li>preventive and curative elements </li></ul><ul><li>implemented by families, communities and health facilities </li></ul>Integrated Management of Childhood Illnesses (IMCI)
    20. 23. IMCI example chart
    21. 24. <ul><li>No Plumpy Nut or Zinc in the smaller Health Centers </li></ul><ul><li>Minimal follow-up </li></ul><ul><li>Little time for dietary counseling </li></ul>
    22. 25. Bhutta, Lancet 2008 Proportional reduction in deaths before 36 months of age Relative reduction in prevalence of stunting at 36 months of age Millions of DALYs averted 99% coverage with balanced energy protein supplementation 2.9% 0.3% 7.1 (2.8%) 99% coverage with multiple micronutrient supplementation in pregnancy 1.6% 0.1% 4.0 (1.5%) 99% coverage with breastfeeding promotion and support 9.1% 0% 21.9 (8.6%) 99% coverage with vitamin A 7.2% 0% 17.6 (6.9%) Proportional reduction in deaths before 36 months of age Relative reduction in prevalence of stunting at 36 months of age Millions of DALYs averted General Nutrition Interventions 13.4% 15.5% 33.8 (13.3%) Micronutrient interventions 12.1% 17.4% 31.3 (12.3%) Disease control interventions 2.6% 2.7% 6.6 (2.6%)
    23. 26. <ul><li>International guidelines </li></ul><ul><li>Local context </li></ul><ul><li>Traditional practices </li></ul><ul><li>DO NO HARM </li></ul><ul><li>KNOW YOUR RESOURCES </li></ul><ul><li>WEAR OTHER’S SHOES </li></ul><ul><li>GREATEST IMPACT IS IN THE COMMUNITY  HEALTH PROMOTION </li></ul><ul><li>Historical and socioeconomic context </li></ul><ul><li>Don’t jump to judgments or conclusions </li></ul><ul><li>Patience and flexibility </li></ul>

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