Childhood Malnutrition Study Design (Haiti, 2009)
Medical Missionaries conducted a study in 2009 to evaluate the best way to treat acute childhood malnutrition at St. Joseph Clinic in Thomassique, Haiti.
Read the full report below, or download it as it appeared in the Icahn School of Medicine at Mount Sinai’s Annals of Global Health “Treating Childhood Malnutrition in Rural Haiti” (PDF).
Read more about Medical Missionaries’ subsequent implementation of its Nutritional Supplement Program (Medika Mamba) at the Clinic.
Community-Based Therapeutic Care (CTC) in Thomassique, Haiti:
Exploring the Potential of the CTC Model for Treating Acute Childhood Malnutrition
By Nick Cuneo and Rita Baumgartner (April 2009)
CONTENTS
I. INTRODUCTION AND BACKGROUND
II. DEFINITIONS
III. THERAPEUTIC FEEDING PROGRAMS AND THE CTC MODEL
IV. STATEMENT OF NEED
V. GENERAL OBJECTIVES
VI. STUDY PROTOCOLS
A. Case-Finding
B. CTC Enrollment and Screening for OTP Study
C. OTP Admission
D. OTP Follow-up Care
E. Discharge from the OTP Study
VII. DATA AND ANALYSIS
VIII. SUPPLIES & BUDGET
IX. WORKS CITED
I. INTRODUCTION AND BACKGROUND
People are considered to be malnourished (more specifically, undernourished) when they do not consume adequate calories, protein, and nutrients to satisfy their bodies’ growth and maintenance requirements (UNICEF, 2006). Long dismissed as an indirect—even negligible—factor in child mortality, acute malnutrition is now indicted for its insidious and indeed major role in eight of the eleven million child deaths that occur worldwide on an annual basis (ScienceDaily, 2003). Malnutrition is a major concern in Haiti, where 22% of children under the age of five are reported to be underweight (Population Reference Bureau, 2008).
Severe malnutrition is directly implicated in over a million child deaths each year (World Health Organization, 2006) and is defined as severe wasting (weight-for-height that is more than three standard deviations below the median World Health Organization (WHO) growth standards) and/or the presence of nutritional edema (swelling of the legs due to protein deficiency) (Prudhon, Prinzo, Briend, Daelmans, & Mason, 2006). There are about 20 million severely malnourished children worldwide, who make up an estimated 2% of the child population in underdeveloped countries (Briend, Prudhon, Prinzo, Daelmans, & Mason, 2006; World Health Organization, World Food Programme, United Nations System Standing Committee on Nutrition and United Nations Children’s Fund, 2007). The prevalence of severe malnutrition in Haiti has most recently been reported as 2.2% (Childinfo, 2008).
Moderate malnutrition has a much higher prevalence than severe malnutrition and is responsible for a far greater number of child deaths annually; indeed, children with moderate malnutrition are up to 12 times more likely to succumb to preventable disease (e.g., measles, malaria, diarrhea, pneumonia) than well nourished children (ScienceDaily, 2003). Defined by a weight-for-age score between two and three standard deviations below the median WHO child growth standards, moderate malnutrition can evolve into severe malnutrition if not treated effectively (Briend, Prudhon, Prinzo, Daelmans, & Mason, 2006). The prevalence of moderate malnutrition in Haiti has most recently been reported as 6.9% (Childinfo, 2008).
The United Nation’s Millennium Development Goals were set out to galvanize nations and organizations across the globe to come together to meet the needs of the world’s poorest and most vulnerable inhabitants. Addressing childhood malnutrition falls under two of these eight goals: eradicating extreme poverty and hunger (goal 1) and reducing child mortality (goal 4).
While international agencies have long engaged in preventive efforts to curb malnutrition in countries such as Haiti through the support of large-scale food provisioning programs (e.g., World Vision), therapeutic treatment programs for malnourished children are not nearly as widespread (Briend, Prudhon, Prinzo, Daelmans, & Mason, 2006). While preventive programs are an essential part of combating malnutrition, they have not been proven effective in treating acute malnutrition (i.e., providing adequate energy for catch-up growth) (Briend, Prudhon, Prinzo, Daelmans, & Mason, 2006). As a result, millions of children are continuing to die preventable deaths each year due to a lack of mobilization around this major public health issue.
II. DEFINITIONS
Anthropometry: The measurement of size, weight, and proportions of human body.
Bipedal “Pitting” Edema: Swelling of the feet and ankles caused by collection of fluid in the tissues (GEMSsite.com, 2008). Bipedal edema is symptomatic of severe malnutrition (i.e., kwashiorkor) and results when fluid shifts out of the blood vessels in an attempt to maintain a balance of concentrations between the protein-deprived blood and the surrounding tissue.
Case-Finding: The process by which children with severe malnutrition are found and referred to a CTC program (Myatt, Khara, & Collins, 2006).
Community-based Rehabilitation: “Treatment that is implemented at home with some external input, for example, from a health worker, or treatment that is given at a primary health clinic, a community day-care center, or a residential center in order to achieve catch-up growth” (Ashworth, 2006).
Community-based Therapeutic Care (CTC): A new model of delivering care that uses decentralized networks of outpatient treatment sites (e.g., an existing primary health-care center) small inpatient units, and large numbers of community-based volunteers to provide case detection and follow-up of patients in their home settings. (Myatt, Khara, & Collins, 2006)
Community-based Volunteer: An unpaid member of the community who volunteers his/her time to assist in case-finding or enrollment, for example, for a CTC program.
Day-Care Nutrition Center: First introduced 50 years ago, day-care nutrition centers consist of simple buildings where around 30 mildly to moderately malnourished children could attend for 6-8 hours a day, 6 days/week to receive three meals for 3-4 months. Mothers would help with the cooking and cleaning and receive education on nutrition and child care. Since their introduction day-care centers have waned in popularity, likely due to the time constraints placed on caregivers, who were obligated to attend for hours each day. (Ashworth, 2006)
Domiciliary Rehabilitation: Therapeutic care that is supplied to the caregiver to be provided in the patient’s home. Considered a “growth area” in therapeutic care since the advent of RUTF such as BP100 and Plumpy’nut (Ashworth, 2006).
Food Provisioning: The provisioning of food by international organizations (e.g., World Vision, the World Food Programme) to people living in food insecure areas of the developing world in an effort to prevent malnutrition.
Height-for-Age: An anthropometric measure used to calculate extent of stunting.
Kwashiorkor: A form of protein-energy malnutrition (PEM) that results from insufficient protein intake combined with fair to good consumption of total calories. Often presenting with large, protuberant bellies, patients with kwashiorkor are characterized by bilateral pitting edema and a weight-for-height score greater than or equal to -2 SD. (Voorhees, 2006)
Marasmus: A form of protein-energy malnutrition (PEM) that results in a shrunken wasted appearance. Often observed in infants who are breastfeeding after a significant decrease in the amount of milk consumed or, more frequently, in those who are artificially fed. Chronic diarrhea is often observed among marasmic patients. (Gehri, Stettler, & Di Paolo, 2006)
MedikaMamba: A locally produced RUTF manufactured in Cap Haitien, Haiti by Meds and Food for Kids, a St. Louis, USA-based nonprofit organization (http://www.medsandfoodforkids.org).
Middle Upper Arm Circumference (MUAC): An anthropometric measure used to assess extent of malnutrition, MUAC has been shown to perform better than other methods in detecting malnutrition and mortality risk and is the best method in terms of age independence, precision, accuracy, sensitivity, and specificity. It is also simple, cheap, and acceptable in low-resource field settings where health workers may lack formal education or literacy. (Myatt, Khara, & Collins, 2006)
Moderate Malnutrition (MM): Defined as a weight-for-age between -3 and -2 standard deviations below the median of the WHO child growth standards (World Health Organization, 2008).
Non-responder: A CTC patient who does not gain weight after being enrolled for at least 4 months and subjected to all available treatment options (Myatt, Khara, & Collins, 2006).
Outpatient Therapeutic Program (OTP): A program that treats children with severe malnutrition (without complications) on an outpatient basis through the provisioning of a ready-to-use therapeutic food (RUTF) and medicines to treat simple medical conditions. Food and medicines are taken at home by the patient, who attends the OTP site on a weekly or bi-weekly (fortnightly) basis for monitoring and resupply. (Ashworth, 2006)
Outreach Worker: A salaried community health worker who is involved in case-finding, patient enrollment, and management for a CTC.
Percentage Weight Gain: A measurement used often in determining if a CTC patient is fit to be discharged from the program. Calculated as ((Current weight-Weight at Admission)/(Weight at Admission x 100))
III. THERAPEUTIC FEEDING PROGRAMS AND THE CTC MODEL
Community-based programs for treating child malnutrition were proposed as early as 50 years ago but have been revolutionized in the last decade with the advent of Ready-to-Use Therapeutic Foods (RUTF). In contrast to in-patient treatment (i.e., hospitalization) of acutely malnourished children—which requires access to a suitable facility (limited in underdeveloped rural areas) and the constant presence of the child’s caregiver (at great cost for the family), while also leaving the child susceptible to hospital-acquired infections—community-based management can treat children who present with non-complicated cases of acute malnutrition at their homes. This method of treatment (domiciliary rehabilitation) has already been shown to be very effective—defined by Ashworth (2006) as “mortality of less than 5% and an average weight gain of at least 5 g/kg/day”—and achieve high levels of coverage in both emergency and non-emergency situations (Prudhon, Prinzo, Briend, Daelmans, & Mason, 2006).
The first community-based programs were proposed by the Spanish doctor Jose María Bengoa in the 1950s. Bengoa initially proposed the “day-care nutrition center” model of therapeutic care, in which plain buildings would be constructed to provide three daily meals to some 30 mildly to moderately malnourished children six days a week for up to four months. Caregivers (usually mothers) would accompany their children to the center, where they would learn about nutrition/feeding and child care. Caregivers and children were required to spend between six and eight hours a day at the center, with heavy emphasis placed on education. While one such center in Bangladesh proved to be effective (Fronczak, Amin, Laston, & Baqui, 1993), the majority reported only limited success (see Ashworth (2006) for review) due to the intense time commitment placed on the caregivers (causing sporadic attendance) and the lack of severely wasted children enrolled (leading to limited opportunity for rapid weight gain).
In very rural areas where distance to such a center would prove prohibitive on a daily basis, Bengoa proposed a residential model of therapeutic care. At these “residential nutrition centers,” children and their caregivers would live on-site, where they would receive daily meals along with education, much like the day-care model (Ashworth, 2006). These centers reached their height in the 1960s and 1970s, but achieved only modest effectiveness, according to Ashworth (2006). Like their day-care counterparts, the residential nutrition centers involved significant costs for the families of the malnourished children, since the primary caregivers would have to leave their households/occupations for large periods of time. Indeed, the popularity of residential nutrition centers has also waned, with only four publications on such centers having been released since 1980 (see Ashworth (2006) for a review of these publications).
The development of RUTFs—high-energy, high-protein, nutrient-rich products that do not require any preparation or equipment on the part of the caregiver—has revolutionized community-based management of acute child malnutrition and made possible a new model for treatment: domiciliary rehabilitation under the support of a Community-based Therapeutic Care (CTC) program. With the advent of BP100 and Plumpy’nut, the two commercially available RUTFs, as well as their many locally produced equivalents (e.g., MedikaMamba), a majority of acutely malnourished children can now be treated on an out-patient basis, with the RUTF being “prescribed” as a medicine, to be taken on a routine basis at the child’s home under the supervision of his/her caregiver. This situation drastically reduces the costs of treatment for both the supervising organization and the acutely malnourished child’s family, since the caregiver and child are only required to travel to the CTC center for RUTF resupply and check-up on a weekly or fortnightly basis. CTC (especially its outpatient component, or Outpatient Therapeutic Program (OTP)) has been the greatest “area of growth” in the management of childhood malnutrition, with many programs reporting significant success (Ashworth, 2006). For a complete review of the CTC model, see Collins, et al., 2006.
This study uses protocols and standards that have been set internationally for the CTC model in order to test the efficacy of a MedikaMamba intervention in Thomassique. By adopting the CTC model of care for the sake of the study, the data collected will be able to be meaningfully and statistically compared with other international programs using RUTF.
IV. STATEMENT OF NEED
As “the hemisphere’s hungriest country” (Mukherjee & Barry, 2008), Haiti faces a situation of chronic food insecurity that continues to devastate its most vulnerable citizens, especially children. At 460 kcal/day, Haiti’s average daily caloric deficit per inhabitant places it among the bottom three-ranked nations worldwide, along with Afghanistan and Somalia (The World Food Programme, 2008). A staggering 22% of Haitian children under five are reported to be underweight, in contrast to just 5% in the neighboring Dominican Republic (Population Reference Bureau, 2008).
Around 31,000 Haitian children under the age of five die each year, leading to an under-five mortality rate of 120 per 1000 children, the 37th worst worldwide (UNICEF, 2008). Moderate and severe malnutrition are identified as the primary cause of death in a full 28% of these deaths and are a contributing factor in many more (The World Food Programme, 2008). A full 40% of Haitian homes face daily food insecurity, with food supply programs covering only 55% of the total population (The World Food Programme, 2008). In every respect, the nutritional situation facing Haitian children is exigent, requiring immediate action on the part of development and relief agencies worldwide.
As shown below in Figure 1, Thomassique is located in an area of highest vulnerability to food insecurity on Haiti’s Central Plateau (USAID, 2008). Malnutrition is certainly observed among children who come to the St. Joseph Clinic, with clinic health professionals estimating there to be about 6-7 severe and 30-40 moderate cases presented each month (Casseus, 2008). Although a preventive food provisioning program is available to pregnant women and their children through World Vision, there is no therapeutic program currently available for the treatment of malnourished children in Thomassique. Without such a program in place, children are undoubtedly wasting away in the area without hope of treatment or recovery.
V. GENERAL OBJECTIVES
- To evaluate the potential of a St. Joseph Clinic-based OTP to treat acute child malnutrition in Thomassique under the CTC model.
- To determine the efficacy of MedikaMamba as an RUTF based on improvements in MUAC, weight, and weight, along with hematocrit, blood glucose, and serum albumin levels.
- To investigate the prevalence and scope of acute child malnutrition in Thomassique.
- To establish an informed estimate for how costly it would be to run a CTC/OTP at St. Joseph’s on a permanent basis.
- To raise awareness and education about the dangers of child malnutrition in Thomassique.
- To identify and train a cadre of community volunteers to carry out an expanded program.
VI. STUDY PROTOCOLS
A. Case-Finding
Children with acute malnutrition will be recruited for the study through three primary mechanisms:
1. Internal Referral: Clinic health professionals will be instructed to take the MUAC for any child patient who appears to be acutely malnourished. If the child’s MUAC is ≤ 120 mm OR if he/she has bipedal pitting edema, they will refer the patient for enrollment into CTC.
2. Community Outreach: Medical Missionaries fellows, the hired outreach worker, and community-based volunteers, will perform community outreach in Thomassique to identify children with acute malnutrition. Children will be recruited for the study if they have an MUAC ≤ 120 mm OR if they appear to have bipedal pitting edema.
3. Community Referrals: If neither internal referral nor community outreach results in adequate numbers of acutely malnourished children being referred to and enrolled in the OTP study, an effort will be made to identify key local leaders (e.g., priests, pastors, school principals) and inform them about the study so that they can make announcements at public gatherings. Attendees will be instructed on the objectives of the study and told to inform parents of children who appear to be malnourished to take their children to St. Joseph Clinic, where they may qualify for enrollment in CTC.
B. CTC Enrollment and Screening for OTP Study
Adapted from a protocol published by the National Center for HIV/AIDS, Dermatology and STI (NCHADS) and Clinton Foundation HIV/AIDS Initiative – Cambodia, 2007.
1. Children will initially have their MUAC, weight, height, and age (to be provided by the caregiver) taken and recorded by the OTP coordinator on an initial dossier (their “OTP Card”—see Appendix 1). Children who have been referred by an outreach worker or community volunteer based on an MUAC measurement taken at their homes (or the presence of edema) will automatically qualify for enrollment based on the outreach person’s records in order to avoid the serious problem of rejected referrals. However, a secondary MUAC reading will be taken by the coordinator and recorded as the formal reading for their OTP Card. Discrepancies between MUAC readings will be noted and explored with the referring worker/volunteer.
2. A child will qualify for enrollment in CTC if he/she meets ANY of the following criteria:
a. MUAC ≤ 120 mm
b. Weight-for-height is at least 2 standard deviations (SD) (≤ 80%) below the median WHO growth standards
c. Presence of bipedal pitting edemes
3. Children qualifying for enrollment will then be registered for entry into CTC after their caregivers give informed consent. Once informed consent is provided, the child will be scheduled for a consultation with a clinic physician.
4. The physician will provide the child with a general check-up, making sure to evaluate the following:
a. Presence/grade of the child’s edemes
b. Respiratory fitness
c. Temperature
d. Hydration
e. Overall health
5. The physician will draw blood from the child to send to the laboratory for serum albumin, hematocrit, and blood glucose testing.
a. If the child is anemic (as determined from the hematocrit reading), he/she will be prescribed the appropriate dosage of ferrous sulfate, to be filled at the pharmacy.
6. If the child is severely malnourished (WHM ≤ -3 S.D. or MUAC ≤ 110 mm) and the HIV status of his/her mother is unknown, the physician will also order an HIV antibody test to establish the child’s HIV status.
a. Any child who tests positive will be referred (and provided transportation) to Hinche to be enrolled in the Zanmi Lasante HIV/AIDS program there.
7. If the child presents symptoms of malaria, the physician will also order a malaria test.
a. If the child has malaria, he/she will be given an initial dose of an anti-malarial (e.g., chloroquine) by the physician as well as a prescription, to be filled at the pharmacy.
8. The physician will then decide if the child is to be admitted in the OTP study or kept as an in-patient according to the following criteria:
a. The patient will be admitted for in-patient treatment if:
i. He/she has grade +++ bilateral pitting edemes OR
ii. Marasmic-kwashiorkor OR
iii. Bilateral pitting edemes AND one of the following:
1. Anorexia
2. Lower respiratory tract infection
3. High fever
4. Severe dehydration
5. Severe Anemia
6. Not alert
7. Hypoglycemia
8. Hypothermia
b. In-patients will stay at the clinic for stabilization until they qualify for admission into the OTP.
c. The patient will be enrolled in the Outpatient Therapeutic Program (OTP) if he/she satisfies the following criteria:
i. Weight-for-height percent of reference median (WHM) ≤-2 S.D. AND
ii. MUAC ≤ 120 mm OR
iii. Presence of grade + or ++ bipedal pitting edemes.
iv. In addition to the above requirements, the consulting physician must certify the following:
1. The child is clinically well
2. The child has an appetite (the child must consume a small dose of the RUTF in front of the physician to qualify for enrollment in the OTP)
3. The child is alert
9. If the child is cleared for admission into the OTP, the physician will provide the OTP coordinator with the OTP Card and lab results from the child’s consultation. A copy of these records will then be made by the OTP coordinator to be filed with the rest of the clinic’s patient files, while the original will be kept with the child’s OTP records. The child will then see the OTP coordinator for formal admission into the OTP.
C. OTP Admission
1. The child and his/her caregiver will sit down with the OTP coordinator for formal admission into the OTP. At this time, the child will be given Oral Rehydration Therapy (ORT) solution to aid in hydration, which he/she may consume during the following education session with the caregiver.
2. The caregiver will be provided with a basic education session on the OTP program and MedikaMamba emphasizing the following messages (adapted from Collins, et al., 2006):
a. Feeding the child MedikaMamba
i. MedikaMamba is a food and medicine for very thin children only. It should not be shared.
ii. Sick children often do not like to eat. Give small regular meals of MedikaMamba and encourage the child to eat often (if possible eight meals a day). Your child should have _____ doses a day.
iii. MedikaMamba is the only food sick/thin children need to recover during their time in OTP.
iv. Always give doses of MedikaMamba before any other food. If child is still hungry after a full dose, he/she may be given a small amount of a nutritious meal until he/she becomes full.
v. For young children, continue to put the child to the breast regularly. Give dose of MedikaMamba immediately after breast milk.
vi. Always offer plenty of clean water to drink while eating MedikaMamba (if possible, we will provide each caregiver with a Klorfasil system and educate them on how to use it at this point).
vii. Use soap (to be provided) for the child’s hands and face before feeding if possible.
viii. Keep food clean and covered.
ix. Sick children get cold quickly. Always keep the child covered and warm.
x. With diarrhea, never stop feeding. Give extra food and extra clean water.
xi. Allergies
1. Though unlikely, there is a small chance of allergic reacting to the peanut butter in MedikaMamba.
2. In case of severe rashes, hives, skin infections, swelling, shortness of breath, or anaphylactic shock, the caregiver must discontinue provisioning of MedikaMamba and bring the child to the clinic immediately.
b. When to return to the clinic outside of regular follow-up visits
i. If the child begins refusing food/not feeding well.
ii. If the child develops a fever.
iii. If the child becomes lethargic or stops responding to touch/voice.
iv. If the child begins to breathe faster than normal.
v. If the caregiver runs out of MedikaMamba for the child before the next scheduled visit.
c. Importance of coming to follow-up visits
i. Acute malnutrition is a potentially life-threatening condition that must be treated very seriously.
ii. MedikaMamba rations are provided on weekly basis and are crucial for the child to make a recovery.
iii. If the caregiver does not bring the child to the follow up appointments, his/her condition could deteriorate and become harder to treat in the future.
d. Rate of improvement during therapy
i. A simple explanation will be provided by the OTP coordinator regarding the child’s expected improvement throughout the course of the program/study.
3. The caregiver will be asked throughout the education session to repeat the messages back to check that they have been fully understood.
4. The caregiver will be provided with a OTP Patient Booklet, which will contain:
a. Daily dosing of MedikaMamba
b. Total amount of MedikaMamba provided at each visit.
c. Date of the clinic visit a week later.
5. After the education session has been completed and the OTP Patient Booklet has been filled out and reviewed with the caregiver, the child will be given folic acid and then brought to the government vaccine provider, who will provide him/her with injections of Vitamin A and the Measles Vaccination (if not already received).
6. After the child’s injections are complete, the caregiver will be provided with a week’s worth of MedikaMamba for the child (plus a couple extra sachets as “buffer stock”).
D. OTP Follow-up Care
1. At each visit to the clinic, the OTP coordinator will:
a. Provide feeding counseling and instruction on how to prepare nutritious, balanced food to keep the child healthy after he/she is discharged from the OTP.
b. Provide the child with any appropriate medications, according to Table 1 (below).
c. Take updated anthropometric measurements for the child, including MUAC, weight, and height.
d. Make updates to the child’s OTP Card and Patient Booklet. The caregiver should bring the Patient Booklet to the clinic for each visit.
e. Refer the child for additional consultation with a physician if deterioration is observed in the child’s condition.
| Table 1. Routine medicines in OTP element of CTC. Taken from Collins, et al., 2006. | ||||
| Product | When | Age/Weight | Prescription | Dose |
| Vitamin A* | At Admission | < 6 months | 50,000 IU | Single dose on admission |
| 6 months to < 1 year | 100,000 IU | |||
| ≥ 1 year | 200,000 IU | |||
| DO NOT USE WITH EDEMA | ||||
| Amoxycillin | ANY OF: MUAC ≤ 110 mm WHM ≤ 70% Bipedal Edema | All beneficiaries | (see protocol) | 3 times a day for 7 days |
| Anti-malarial (follow Haitian Health Ministry protocol) | Positive malaria test | (see protocol) | (see protocol) | (see protocol) |
| FOLIC ACID** | First visit | All beneficiaries | 5 mg | Single dose on admission |
| ALBENDAZOLE | Second visit | < 1 year | DO NOT GIVE | NONE |
| 12-23 months | 200 mg | Single dose on second visit | ||
| ≥ 2 years | 400 mg | |||
| MEASLES VACCINATION | At admission and discharge | From 6 months | (standard) | Once on admission and once on discharge |
*Vitamin A: Do not give if child has already received in last one month. Do not give to children with edema until discharge from OTP.
**Folic Acid: Give on second visit if Fansidar is used as the antimalarial.
2. When possible, the OTP coordinator, as well as community-based volunteers with the study, should make visits to the homes of the children in the program. At these visits, the CTC staff member will:
a. Check on the child’s progress and overall health status, along with his/her adherence to the prescribed MedikaMamba regimen.
i. If any of the following symptoms is observed, the OTP staff member will refer the child back to the clinic immediately:
1. Grade +++ bilateral pitting edemes
2. Anorexia
3. Lower respiratory tract infection
4. High fever
5. Severe dehydration
6. Severe diarrhea
7. Severe anemia
8. Hypoglycemia
9. Hypothermia
10. Lack of alertness
b. Follow up on any/all absences from weekly appointments with the OTP
2. At the end of every week, the OTP coordinator will fill in the “weekly totals for OTP” sheet that records MedikaMamba dosing and outcomes:
a. Number of children registered in the program will be checked against the number of “active” cards in the OTP file (not including discharges).
b. Weekly totals will be used for monitoring and evaluation of the OTP for the study.
E. Discharge from the OTP Study
1. A child may be discharged as “cured” of acute malnutrition if he/she meets the following criteria:
a. Has been enrolled in the OTP for at least four weeks, with at least three recorded visits to the clinic (including the first).
b. Has exhibited a WHM that is ≥ -1 S.D. (≥90%) for at least 2 consecutive visits.
c. Has an MUAC ≥ 130 mm.
d. Has not exhibited edemes for two consecutive visits to the clinic.
e. Has had sustained weight gain for two consecutive visits to the clinic.
f. Appears clinically well.
2. Each child who appears to fulfill the above criteria will be taken to see a physician for a final consultation. This consultation will involve a basic physical examination and blood draw, which will be used to run a final serum albumin, hematocrit, and blood glucose test s(along with any others that were done during the initial consultation) for the sake of comparison.
3. If the child is cleared for discharge by the physician, he/she will return to the OTP coordinator, who will:
a. Provide the caregiver with one week’s supply of MedikaMamba.
b. Provide additional feeding counseling on good nutrition.
c. Inform the caregiver of the food provisioning services available through WorldVision, if applicable.
4. If a child is absent for three consecutive weeks, he/she will be discharged from the OTP study as “defaulted.” The child may reenter the study but will have to receive a new OTP Card and go through the entry process once again.
5. If a child has not achieved the criteria necessary to be discharged as “cured” after three months, he/she will be discharged as “non-cured” and referred to a physician for a consultation and possible admission as an in-patient.
6. If a child dies during their time registered in the OTP study, he/she will be discharged as “died.”
VII. DATA AND ANALYSIS
Detailed records will be kept on each child’s progress throughout the study. In addition to the complete set of health information (e.g., the physician’s qualitative notes, as well as the quantitative figures such as the child’s serum albumin, hematocrit, and blood glucose levels) that will be collected on admission (see VI. Study Protocols – CTC Enrollment and Screening for OTP Study – Sections 1-6) and discharge (see VI. Study Protocols – Discharge from the OTP Study – Section 2), the child’s MUAC, weight, and height will be taken by the OTP coordinator at each weekly visit (including admission and discharge). These data will allow for paired comparisons to be made between the pre- and post-treatment data sets (on both individual and group levels), as well as average rates of improvement (e.g., g/kg/day). Finally, discharge information (i.e., % cured, % defaulted, % non-cured, % died) will be kept to determine the efficacy of the OTP study intervention in comparison to other similar programs.
VIII. SUPPLIES & BUDGET
| Item | Supplier | Cost/Unit | Units | Total |
| MedikaMamba | Meds and Foods for Kids (Cap Haitien, Haiti) | ~$68/treatment | 100 | $6800.00 |
| Klorfasil Water Treatment System | Klorfasil (Hinche, Haiti) | $8.50/system | 100 | $850.00 |
| OTP coordinator salary | $150/month | 4 | $600.00 | |
| Vitamin A | Haitian Health Ministry | provided at no cost | 100 | $0.00 |
| Measles Vaccination | Haitian Health Ministry | provided at no cost | <100 | $0.00 |
| Folic Acid | Medical Missionaries/IDA | already on site | 100 | $0.00 |
| Albendazole | Medical Missionaries/IDA | already on site | 100 | $0.00 |
| Chloriquine | Medical Missionaries/IDA | already on site | <<100 | $0.00 |
| Adult Scale | Medical Missionaries | already on site | 1 | $0.00 |
| Infant Scale | Medical Missionaries | already on site | 1 | $0.00 |
| Soap | Medical Missionaries | already on site | 400 | $0.00 |
| TOTAL | $8250.00 | |||
*This budget is extremely conservative. The Hospital Albert Schweitzer was able to execute their emergency program for an average of $36 per child using MedikaMamba, and it is likely that the actual amount of MedikaMamba per child will come out to be substantially lower than the $68 quoted by Meds and Foods for Kids.
IX. WORKS CITED
Ashworth, A. (2006). Efficacy and effectiveness of community-based treatment of severe malnutrition. Food and Nutrition Bulletin , S24-S48.
Briend, A., Prudhon, C., Prinzo, Z. W., Daelmans, B. M., & Mason, J. B. (2006). Putting the management of severe malnutrition back on the international health agenda. Food and Nutrition Bulletin , S3-S5.
Casseus, F. (2008, November 15). Director, St. Joseph’s Clinic. (C. Cuneo, Interviewer) Childinfo. (2008, June).
Childinfo.org. Retrieved December 29, 2008, from Childinfo.org: Statistics by Area – Undernutrition – Country data: Wasting – Mo: http://www.childinfo.org/undernutrition_wasting.php
Collins, S., Sadler, K., Dent, N., Khara, T., Guerrero, S., Myatt, M., et al. (2006). Key issues in the success of community-based management of severe malnutrition. Food and Nutrition Bulletin , S49-S82.
de Onis, M., Bossner, M., Borghi, E., Frongillo, E. A., & Morris, R. (2004). Estimates of global prevalence of childhood underweight in 1990 and 2015. The Journal of the American Medical Association , 2600-2606.
Fronczak, N., Amin, S., Laston, S. L., & Baqui, A. H. (1993, May). An evaluation of community-based nutrition rehabilitation cnters. Working Paper No. 10, International Centre for Diarrhoeal Disease Research, Bangladesh, May 1993.
Gehri, M., Stettler, N., & Di Paolo, E. R. (2006, May 22). emedicine. Retrieved December 28, 2008, from Marasmus: Overview: http://emedicine.medscape.com/article/984496-overview
GEMSsite.com. (2008). Course Glossary. Retrieved December 20, 2008, from Geriatric Educatoin for Emergency Medical Services: http://www.gemssite.com/course_glossary_showterm.cfm?term=pedal%20edema
Manary, M. J. (2006). Local production and provision of ready-to-use therapeutic food (RUTF) spread for the treatment of severe childhood malnutrition. Food and Nutrition Bulletin , S83-S88.
Mukherjee, J., & Barry, D. (2008, May 5). Feeding Haiti. The Boston Globe .
Myatt, M., Khara, T., & Collins, S. (2006). A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food and Nutrition Bulletin , S7-S22.
National Center for HIV/AIDS, Dermatology and STI (NCHADS) and Clinton Foundation HIV/AIDS Initiative — Cambodia. (2007, July 9). Ready-to-Use Therapeutic Food (RUTF) as a Food Supplement for Treating Severe Acute Malnutrition (SAM) in Children in Cambodia. Retrieved December 29, 2008, from Food Security and Nutrition: http://www.foodsecurity.gov.kh/docs/docsMeetings/RUTF-Training%20Presentation-ENG.pdf
Population Reference Bureau. (2008). Data Comparisons by Topic > Bar Graph > Underweight Children Age <5 (%) Population. Retrieved 12 26, 2008, from Population Reference Bureau: http://www.prb.org/Datafinder/Topic/Bar.aspx?sort=v&order=d&variable=1
Prudhon, C., Prinzo, Z. W., Briend, A., Daelmans, B. M., & Mason, J. B. (2006). Proceedings of the WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children. Food and Nutrition Bulletin , S99-S104.
ScienceDaily. (2003, July 1). Moderate Malnutrition Kills Millions Of Children Needlessly. Retrieved December 29, 2008, from ScienceDaily: http://www.sciencedaily.com/releases/2003/06/030630110813.htm
The World Food Programme. (2008). WFP – Where We Work – Haiti. Retrieved 12 22, 2008, from The World Food Programme: http://www.wfp.org/country_brief/indexcountry.asp?country=332
UNICEF. (2006). Progress for Children: A Report Card on Nutrition.
UNICEF. (2008). The State of the World’s Children 2008. Retrieved December 27, 2008, from UNICEF – Monitoring and Statistics: http://www.unicef.org/sowc08/docs/sowc08.pdf
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World Health Organization. (2006). WHO, UNICEF, FANTA African Regional Training on Integrated Management of Severe Malnutrition, Dar es Salaam, 20th to 30th September 2006. Retrieved December 27, 2008, from World Health Organization: http://www.who.int/nutrition/topics/severemalnutrition_tranining_tanzania/en/index.html
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| St. Joseph Clinic Thomassique, Haiti |
| Medical Missionaries Manassas, VA, USA |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||
No. Dossier PTCE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Programme Thérapeutique de Consultations Externes (PTCE) pour la Malnutrition d’Enfant Pwogram Kominotè kont Malnitrisyon Timoun Outpatient Therapeutic Program (OTP) for Childhood Malnutrition | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A. Inscription Patiente / Enskripsyon Pasyan / Patient Enrollment | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1. | Nom de famille de l’enfant : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| non fanmi pou timoun nan / child’s family name | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2. | Prénom de l’enfant : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| prenon timoun nan / child’s first name | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3. | L’enfant a-t-il une carte de visite hospitalière ? | □ | Non | □ | Oui → | No. Dossier : |
| |||||||||||||||||||||||||||||||||||||||||||||||||||
| èske timoun nan genyen yon kat didante pou lopital la? |
| non / no |
| wi / yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||
4. | Sexe : | □ | Garçon | □ | Fille | 5. | Date de naissance : | / / | jj/mm/aaaa | |||||||||||||||||||||||||||||||||||||||||||||||||
| sèks / sex |
| gason / boy |
| fi / girl |
| anivèsè / date of birth | dd/mm/yyyy | ||||||||||||||||||||||||||||||||||||||||||||||||||
6. | Référence : | □ | Médecin de clinique | □ | Volontaire de santé | □ | Autre : | |||||||||||||||||||||||||||||||||||||||||||||||||||
| referans / reference |
| doktè klinik / clinic doctor |
| volontè sante / health volunteer |
| lòt / other | |||||||||||||||||||||||||||||||||||||||||||||||||||
7. | Papiers de référence : | □ | Non | □ | Oui | 8. | Perimetre brachial (mm) : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| papye referans / ref. papers |
| non / no |
| wi / yes |
| perimèt bra / brachial circumference | |||||||||||||||||||||||||||||||||||||||||||||||||||
9. | Taille (cm) : |
| □ Couché | 10. | Poids (kg) : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| wotè / height | □ Debout |
| pwa / weight | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
11. | Oedème : | □ | Non | □ | Oui | 12. | Température (°C) : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| edèm / edema |
| non / no |
| wi / yes |
| tanperati / temperature |
| ||||||||||||||||||||||||||||||||||||||||||||||||||
13. | Critère d’admission : | □ | Poids/Taille: Moderée | □ | Poids/Age | □ | Oedème | |||||||||||||||||||||||||||||||||||||||||||||||||||
| (cocher ce qui s’applique) |
| weight/height: moderate |
| weight/age |
| edemas | |||||||||||||||||||||||||||||||||||||||||||||||||||
| kritè pou admisyon /criteria for admission | □ | Poids/Taille: Sévère | □ | Perimetre brachial | □ | Papiers de référence | |||||||||||||||||||||||||||||||||||||||||||||||||||
|
| weight/height: severe |
| brachial circumference |
| official reference papers | ||||||||||||||||||||||||||||||||||||||||||||||||||||
14. | Nom du parent ou gardien responsable : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| non moun ki reskonsab timoun nan / name of child’s parent or guardian | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15. | Localité où la famille de l’enfant habite : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| zòn kote fanmi timoun nan rete / area where the child’s family lives | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16. | Nombre total dans la maison : |
| 17. | Distance à la maison (en minutes) : |
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
| konbyen moun rete nan kay la / number in household |
| jouk ki bò timoun nan rete / distance to house | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
18. | Le gardien donne-t-il le consentement d’entrer dans l’étude ? | □ | Oui | □ | Non (ne continuer pas) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| èske moun ki reskonsab pou timoun nan bay pèmisyon pou antre etid la? |
| wi / yes |
| non (pa kontinye) / no (do not continue) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
19. | Si oui, allouez l’enfant un nombre de dossier pour le PCTE et écrivez-le sur le haut de la page | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| si wi, bay timoun nan yon nimewo dosye pou PCTE a e ekri l anwò paj la / if yes, assign the child an OTP number and write it on the top of the page | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20. | Date d’admission : | / / | jj/mm/aaaa | 21. | Réadmission ? | □ | Non | □ | Oui | |||||||||||||||||||||||||||||||||||||||||||||||||
| dat admisyon / entry date | dd/mm/yyyy |
| reyadmisyon / readmission |
| non / no |
| wi / yes | ||||||||||||||||||||||||||||||||||||||||||||||||||
B. Consultation Préliminaire / Konsiltasyon Preliminè / Preliminary Consultation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1. | Nom du docteur qui exécute la consultation : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| non doktè k ap fè konsiltastyon an / name of consulting physician | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2. | Diarrhée ? | □ | Non | □ | Oui | 3. | Poupes / jour : | □ | 1 – 3 | □ | 4 – 5 | □ | >5 | |||||||||||||||||||||||||||||||||||||||||||||
| dyare / diarrhea |
| non / no |
| wi / yes |
| chak ki lè li fè twalèt |
|
|
|
|
|
| |||||||||||||||||||||||||||||||||||||||||||||
4. | Nausée ou vomi ? | □ | Non | □ | Oui | 5. | Passe l’urine ? | □ | Non | □ | Oui | |||||||||||||||||||||||||||||||||||||||||||||||
| kè plen / nausea or vomiting |
| non / no |
| wi / yes |
| fè pipi / passes urine |
| non / no |
| wi / yes | |||||||||||||||||||||||||||||||||||||||||||||||
6. | Toux ? | □ | Non | □ | Oui | 7. | Appétit : | □ | Bon | □ | Mal | □ | Aucun | |||||||||||||||||||||||||||||||||||||||||||||
| tous / cough |
| non / no |
| wi / yes |
| lapeti / appetite |
| good |
| poor |
| none | |||||||||||||||||||||||||||||||||||||||||||||
8. | Tête-t-il ? | □ | Non | □ | Oui | 9. | Allergies : |
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| pran tèt / nursing |
| non / no |
| wi / yes |
| alèji / allergies | |||||||||||||||||||||||||||||||||||||||||||||||||||
11. | Oedème : | □ | Non | □ | Oui → | Qualité : | □ | + | □ | ++ | □ | +++ | ||||||||||||||||||||||||||||||||||||||||||||||
| edèm / edema |
| non / no |
| wi / yes | kalite / grade |
|
|
|
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||
12. | Eveillé ? | □ | Non | □ | Oui | 13. | Handicapé ? | □ | Non | □ | Oui | |||||||||||||||||||||||||||||||||||||||||||||||
| eveye / alert |
| non / no |
| wi / yes |
| kokobe / handicapped |
| non / no |
| wi / yes | |||||||||||||||||||||||||||||||||||||||||||||||
14. | Bouche : | □ | Normal | □ | Amygdalite | □ | Sèche | □ | Plaies | □ | Candida | |||||||||||||||||||||||||||||||||||||||||||||||
| bouch / mouth |
| normal |
| tonsilitis |
| dry mouth |
| sores |
| yeast infection | |||||||||||||||||||||||||||||||||||||||||||||||
