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Conventional methods of classifying causes of death suggest that about 70% of the deaths of children 0-4 years old worldwide are due to diarrheal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (ages 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The methodology is based on the results of 8 community-based, prospective studies of the relationship between anthropometry and child mortality from the rural areas of Bangladesh, India, Indonesia, Malawi, Papua New Guinea, and Tanzania. These studies suggest that the risk of mortality increases at a compounded rate of 5.9% for each percentage point decline in weight-for-age below the reference point of 90% weight-for-age. Using the relative risk estimates, the standard epidemiological statistic of population-attributable risk (PAR) was used to estimate the percentage of child deaths attributable to malnutrition's potentiating impact on infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicated that 56% of child deaths were attributable to malnutrition's potentiating effects. 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition, with a range of 73-74% in Bangladesh and India to a high of 100% in countries with very low malnutrition prevalences. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% in Paraguay to 67% in India, with at least 3/4 of this arising from mild-to-moderate malnutrition in each case. The powerful impact of malnutrition on child mortality suggests that strategies involving only the screening and treatment of the severely malnourished are not sufficient.
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PMID:The effects of malnutrition on child mortality in developing countries. 755 15

The dilemma of private practitioners is whether to prescribe or not to prescribe iron supplements on suspicion of anaemia. This cross sectional study was done in an urban squatter settlement with a primary health care centre to assess the significance of symptoms and a history of associated diseases in the diagnosis of anaemia. A total of 321 children were sampled from 1800 children < 5 years of age in a population of 11,000, by systematic random sampling. Mothers were asked about the presence of assumed associated symptoms and diseases which were listlessness, irritability, anaemia, pica, poor weight gain, diarrhoea, acute respiratory infection and malaria in last 3 months. There was significant association between anaemia (Hb < 11 gms%) and irriability (P < .02), anorexia for solid foods (P < .04), pica (P < .001), episode of diarrhoea (P < .001) and poor weight gain (P < .006). There was no significant association between malaria, cold, cough and anaemia. Children with these symptoms complex should receive iron supplements.
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PMID:Anaemia in children: Part II. Should primary health care providers prescribe iron supplements by the observation and presence of assumed symptoms? 786 85

This study provides the age specific prevalence rates of diseases using data from 1152 infants by reviewing clinic records, which have been maintained from 1963 till 1984 (grouped according to households) at Kasangati Health Centre near Kampala, Uganda. On the average, each child reported 3 disease episodes per year. The conditions that brought a child to clinic for the first time were: respiratory infection 46.2%; clinical malaria 14.4%; skin infections 9.8%; diarrhoeal diseases 8.5% and, others 21.1%. The prevalence of diseases in infants at the age of less than one month old were, respiratory tract infection 78/1000, skin conditions 29/1000, clinical malaria/fever 18/1000, eye infection 15/1000, diarrhoea 5/1000 and others 67/1000. At the age of one month till the age of 18 months, four conditions consistently topped the disease prevalence list: respiratory tract infection with a range of 175/1000 to 29/1000, being higher in early childhood; clinical malaria/fever with a range of 79/1000 to 23/1000; diarrhoeal diseases with a range of 55/1000 to 10/1000 and skin conditions with a range of 42/1000 to 10/1000. Other disease conditions including urinary tract infection, burns/accidents, eye infections, ear infections, measles and tetanus had age specific prevalence of less than 10/1000 at each age. Most of the diseases showed decreasing level of prevalence as the age increased. Relatively more people used the clinic and at a higher rate in the 1970s compared to the 1960s, mirroring the general economic and political situation of the two periods. There were no sex specific differences in either the frequency of utilization of the clinic or in the prevalence of disease over time.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Record keeping on early childhood diseases in two decades, at the health centre level in Uganda. 795 70

The study aim was to evaluate the impact of mortality and primary health care (PHC) services utilization prior to death, based on data from the mortality surveillance system in the Upper River Division (URD) of The Gambia. The sample of villages with greater than 400 persons included 355 villages with a voluntary village health workers (VHW) and/or a trained traditional birth attendant (TBA), and 9 villages without. Recording of births and deaths was accomplished by one registrar for every 200 children or under, and totaled 373 village registrars and 8 field workers covering a population of 133,000. Cause of death for children aged 5 years was determined by 3 physicians and collected for senior field assistants. Morbidity data for children was gathered from monthly forms completed by VHWs and BAs. VHWs and TBAs were trained 6=8 weeks at Basse Hospital and 4-6 weeks at Bansang Regional Hospital, respectively, with periodic retraining. Local PHC centers provided health education, environmental health education, immunization, nutrition, treatment and referral. There were 6 health centers in URD, which was the base of operations for travel to 5-6 sites 1-2 times per month for running clinics, evaluation of referred patients, and supervision of PHC activities. There were 16, 216 episodes of malaria, 6111 episodes of respiratory infection (ALRI), and 6380 episodes of acute gastroenteritis reported through the PHC system. That means .63, .23, and .25 episodes per person per year, respectively. More than 50% of cases of ALRI involved consultation with VHWs. There were 915 deaths among children aged 5 years in one year. Of the 94% reports on the deaths made by relatives, there were 85% dying at home, and 8% dying at a health center or hospitals. 13% (117) were inpatients during a portion of the precipitating illness. Survivors of illnesses were higher among those children receiving consultation with the VHW. Only 33% of children who died had consulted a VHW during the final illness. TBAs reported 50% of deaths recorded by the surveillance system. TBAs are selectively consulted.
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PMID:Comparison of mortality between villages with and without Primary Health Care workers in Upper River Division, The Gambia. 817 5

Vitamin A toxicity is a concern among health care providers, especially when present recommendations for vitamin A may result in multiple dosing during a short period of time. We observed no vitamin A toxicity in 5 children who received multiple high doses of vitamin A. These 8-month to 5-year-old children were part of a community trial of vitamin A during acute measles, and were being treated at a local hospital for severe acute respiratory infection, malaria, and/or diarrhoea. One 12-month-old who received 1,612,500 I.U. within a period of three weeks showed elevated serum retinol (3.42 mumol/l), but none of the five showed signs of toxicity. These cases illustrate the confusion surrounding the correct use of vitamin A for infants and children with multiple morbid conditions. A plea is made to report similar situations since clinical trials are unethical.
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PMID:Multiple high dose vitamin A supplementation. A report on five cases. 856 May 95

Political and social conditions deteriorated in Somalia during the 1980s before the onset of civil war in 1990. A cohort study of mortality among children under age 5 years was conducted in Lama-Doonka and Buulalow villages during 1987-89, a period of economic and political collapse in the rural parts of the country. Mortality among the children increased from 211/1000 in 1987 to 323/1000 in 1988 and 414/1000 in 1989. Boys and infants were at greater risk of death relative to girls and children aged 1-4 years, respectively. Respiratory infections, diarrheal diseases, fever/malaria, and tetanus during the prenatal period were the major signs before death. Mortality rates for diarrheal diseases increased significantly over the period, while rates for respiratory infections and diseases preventable by immunization increased more slowly. The increasing trend in under-five mortality was more pronounced when the mother derived her major income from sources other than farming and in larger households.
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PMID:Child mortality in a collapsing African society. 900 35

Data collected from 200 children admitted to a hospital on the Kenyan coast who met a broad definition of severe acute respiratory infection (ARI) indicated that simple clinical signs alone are unable absolutely to distinguish severe ARI and severe malaria. However, laboratory data showed that marked differences exist in the pathophysiology of unequivocal malaria and unequivocal ARI. Children in the former group had a higher mean oxygen saturation (97 vs. 94, P < 0.001), mean blood urea level (5.3 vs. 1.9 mmol/L, P < 0.001) and geometric mean lactate level (4.5 vs. 2.1 mmol/L, P < 0.001), and lower mean haemoglobin level (5.3 vs. 9.0 g/dL, P < 0.001) and base excess (-9.4 vs. -2.6, P < 0.001) than those in the latter group. Using these discriminatory variables it was estimated that up to 45% of children admitted with respiratory signs indicative of severe ARI probably had malaria as the primary diagnosis. Radiological examination supported this conclusion, indicating that pneumonia characterized by consolidation was uncommon in children with respiratory signs and a high malarial parasitaemia (> or = 10,000/microliters). There is no specific radiological sign of severe malaria. In practice, all children with respiratory signs warranting hospital admission in a malaria endemic area should be treated for both malaria and ARI unless blood film examination excludes malaria. In those with malaria and clinical evidence of acidosis, but no crackles, antibodies may be withheld while appropriate treatment for dehydration and anaemia is given. However, if clinical improvement is not rapid, antibiotics should be started.
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PMID:Clinical overlap between malaria and severe pneumonia in Africa children in hospital. 901 8

A surveillance system was used to detect births and deaths in children in a large, rural, West African population from 1989 to 1993. Cause of death was investigated using post-mortem questionnaires. Overall infant (age 0-11 months) and child (age 1-4 years) mortality rates of 80.1 and 18.8 per 1000 per year were recorded. These were reasonably consistent over the period of surveillance. The most frequent cause of death in infants was acute respiratory infection (ARI), whereas in children it was malaria: these two conditions accounted for 41% of the deaths in children under 5 years old. Other leading causes of death were acute gastroenteritis, malnutrition, and septicaemia. Deaths attributed to ARI decreased over the 5-year period, but mortality rates from other causes were either unchanged or increased slightly. Mortality from all causes peaked in the rainy season and was slightly higher in villages which were part of a primary health care programme than in those which were not. There were also no differences between male and female mortality rates beyond one year of age. Despite the introduction of a number of health interventions, there has been no major change in the overall pattern of mortality in children in a rural area of The Gambia. Malaria and ARI remain the main causes of death.
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PMID:Changes in the pattern of infant and childhood mortality in upper river division, The Gambia, from 1989 to 1993. 901

The World Health Organization (WHO) has developed a diagnostic and treatment algorithm to facilitate the rapid identification and management of severely ill children in developing countries. 13 indicators are listed on Sick Child Charts: inability to drink, abnormal mental status (e.g., sleepiness), convulsions, wasting, edema, chest wall retraction, stridor, abnormal skin turgor, repeated vomiting, stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and corneal ulceration. These indicators target the principal causes of child mortality: acute respiratory infection, malaria, measles, diarrheal disease, and malnutrition. The usefulness of the WHO algorithm was evaluated in 4 clinics in western Kenya's Siaya district and in the pediatric outpatient and inpatient departments of Siaya District Hospital. 770 (28%) of the 2799 children (mean age, 13 months) seen in these rural outpatient clinics had 1 or more of the 13 signs, most frequently repeated vomiting (13%). Children with any of these signs had a 2.3 times higher odds of hospitalization than those without such signs; however, 424 admitted children (54%) had none of the 13 signs. Pallor and chest wall retraction were most highly associated with hospital admission (odds ratio [OR], 8.6 and 5.3, respectively). Among the 1139 inpatients, 666 (58%) presented with at least 1 sign and 75 (7%) died, 67 (89%) of whom had at least 1 clinical sign at admission. Overall, the mortality risk associated with having at least 1 sign was 6.5 times higher than that for children with none of the signs. The signs most associated with mortality were abnormal mental status (OR, 59.6), poor skin turgor (OR, 5.6), pallor (OR, 4.3), repeated vomiting (OR, 3.6), chest wall retraction (OR, 2.7), and edema (OR, 2.4). Although studies in other settings are required to validate the WHO logarithm, this schema appears to be a feasible means for identifying high-risk children in developing countries.
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PMID:An evaluation of clinical indicators for severe paediatric illness. 906 Feb 22

The purpose of this study carried out in the pediatric ward of the regional hospital in Moundou, Chad, between June 1992 and May 1993 was to assess the prevalence of protein-energy malnutrition in children under 5 years of age and its relationship with various diseases and in-hospital mortality. A total of 1050 children ranging in age from 1 to 59 months were hospitalized in the ward during the study period and included in the study. Nutritional status was assessed using weight-for-height (W/H) and height-for-age (H/A) charts. Diarrhea, dehydratation, malaria, anemia, acute respiratory infection, and meningitis accounted for 85.5% of the underlying diseases and for 76% of deaths. At entry into study the prevalence of malnutrition was 63.1% (W/H < -2 Z-score) including 37% with severe malnutrition (W/H < -3 Z-score) and 16.1% with stunted growth (H/A < -2 Z-score). Malnutrition was more prevalent in children under than over 2 years of age (80% vs. 42.7% respectively). The same trend was observed with regard to severe malnutrition. The prevalence of malnutrition was highest in children with acute respiratory infections or diarrhea (61.3% and 89.8% respectively). Mortality was significantly higher in severely malnourished children and malnourished children with respiratory infection especially at ages under 1 year. Death was attributed to malnutrition in 30% of cases. Better low cost nutritional care is currently feasible. The most cost efficient methods of fighting against this problem are prevention and education especially concerning breast feeding.
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PMID:[Evaluation of the nutritional status of children less than 5 years of age in Moundou, Chad: correlations with morbidity and hospital mortality]. 928 10


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