Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.) Module Three: Nutrition and diarrhea (introduction...) Session 7 - Nutrition during and after diarrhea (introduction...) Handout 7A: The diarrhoea-malnutrition complex Handout 7B: Carry on feeding Handout 7C: Breast to family diet Handout 7D: Persuading children with diarrhoea to eat Trainer Attachment 7A: Problem poster activity Trainer Attachment 7B: Nutrition counseling demonstration Trainer Attachment 7C: Therapy begins at home Trainer Attachment 7D: Enriched ORT Trainer Attachment 7E: Child description and recommended diet Session 8 - Recognizing malnutrition (introduction...) Handout 8B: Weight for height (stature) for both boys and girls Handout 8C: Weight for age chart Handout 8D: How to measure weight-for-length Handout 8E: Recording the weight on a growth chart Handout 8F: Measures recording sheet Trainer Attachment 8A: Comparison of anthropometric measures Trainer Attachment 8B: Growth monitoring Trainer Attachment 8C: Growth chart exercise Session 9 - Preventing malnutrition (introduction...) Handout 9A: Multimixes as village level weaning foods Trainer Attachment 9A: Ali's story Trainer Attachment 9B: Case studies Trainer Attachment 9C: Nutritional rehabilitation centers Trainer Attachment 9D: Guide for multimix preparation stations

Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)

Module Three: Nutrition and diarrhea

OVERVIEW

Sessions in this module focus on understanding the "vicious circle" of diarrhea and malnutrition and developing skills to break the circle through appropriate diet during and after diarrhea, growth monitoring, nutritional counseling and nutritional rehabilitation. Session 7 presents nutritional needs during and after diarrhea. Session 8 covers growth measurement and growth charting to identify children "at risk" for malnutrition and disease. Session 9 focuses on interventions to prevent malnutrition through health education.

OBJECTIVES

· To accurately list the appropriate kinds and amounts of foods for a child, or a specific age and weight, during and after diarrhea, following the WHO recommendations.

· To counsel a mother appropriately about diet during and after diarrhea, using the rules for counseling stated in Session 7.

· To correctly identify at least five signs and symptoms of children at high risk for malnutrition and disease.

· To explain how to use and interpret anthropometric measures for the identification of high risk children according to the guidelines in Session 8.

· To describe at least four strategies for preventing malnutrition as stated in Session 9.

Cross reference with the Technical Health Training Manual:

Session 28 Foods and Nutrition
Session 29 Recognizing Malnutrition
Session 30 Breastfeeding and Weaning
Session 31 Preventing Malnutrition
Session 34 Well Baby Care

Session 7 - Nutrition during and after diarrhea

TOTAL TIME

3 hours

OVERVIEW

Diarrhea and malnutrition are mayor causes of childhood illness and death in less developed countries. The interaction of diarrhea and malnutrition is complex and still not fully understood, Malnourished children appear to suffer more severe episodes of diarrhea than healthy children. Diarrhea, more than any other infection, causes serious growth faltering in many areas of the world. In this session participants learn about proper nutrition during and after diarrheal episodes by watching and discussing a demonstration of nutrition counseling in the home. They also discuss the importance of breastfeeding and supplementary weaning foods with particular attention to cultural attitudes toward feeding during diarrhea, Participants practice counseling mothers about foods to give a child during and after diarrhea.

OBJECTIVES

· To explain the concept of the "vicious circle" of diarrhea, malnutrition and illness. (Step 1)
· To describe appropriate foods to feed a child during and after diarrhea. (Steps 2-4)
· To counsel a mother about child nutrition during and after diarrhea. (Steps 5, 6)

MATERIALS

Markers, newsprint and posterboard

RESOURCES

- "Oral Rehydration Therapy (ORT) for Children," pp. 53-54. (ORT Resource Packet)
- Infant Nutrition in the Subtropics and Tropics, pp. 236-268
- Treatment of Diarrhoea pp. 4-6.
- Helping Health Workers Learn, Chap. 25
- Community Culture and Care, pp. 189-195, and Chap. 12.
- Technical Health Training Manual. Sessions 28 and 29. (Peace Corps)

Handouts:

- 7A The Diarrhoea Malnutrition Complex
- 7B Carry on Feeding
- 7C Breast to Family Diet
- 7D Persuading Children With Diarrhea to Eat

Trainer Attachments:

- 7A Problem Poster Activity
- 7B Nutrition Counseling Demonstration
- 7C Therapy Begins at Home
- 7D Enriched ORT
- 7E Sample Child Description and Recommended Diet

PROCEDURE

Trainer Note

It is assumed that participants have some knowledge of child nutrition and the conditions and beliefs that affect feeding practices and nutritional status in their communities. Use the resources listed above to supplement participants" knowledge if necessary.

Prepare the posters for Step 1 using Trainer Attachment 7A (Problem Poster Activity).

Invite a health worker(s) with skill in nutrition counseling to participate in this session during the nutrition counseling demonstration and practice. Ask two participants to help with the preparations for this demonstration. Trainer Attachment 7B (Nutrition Counseling Demonstration) offers suggestions for this activity.

Step 1 (25 min)

Recognizing the Vicious Circle of Diarrhea and Malnutrition

Introduce the session using Trainer Attachment 7A (Problem Poster Activity). Distribute Handout 7A (The Diarrhea Malnutrition Complex) as supplementary reading.

Step 2 (25 min)

Nutrition Counseling Demonstration

Present the demonstration of counseling about nutritional needs during and after diarrhea. After the demonstration discuss the following questions:

- Why is it important to continue feeding during and after diarrhea?
- Why is important to continue breastfeeding?
- What do you feed a child during diarrhea?
- What do you feed a child after diarrhea?
- What local cultural practices could help or hinder you in convincing mothers to continue feeding during diarrhea?

Distribute Handouts 7B (Carry on Feeding), 7C (Breast to Family Diet) and 7D (Persuading Children With Diarrhea to Eat) as supplementary reading.

Trainer Note

Emphasize availability and cultural acceptability of foods as important guidelines to what to feed a child during and after diarrhea. Trainer Attachment 7C (Therapy Begins at Home) and 7D (Enriched ORT), Treatment of Diarrhoea, pages 4-6, and "Oral Rehydration Therapy (ORT) for Children" pages 53-54, provide background for leading this discussion. Allow time for participants to ask questions about nutrition and diarrhea.

An alternative approach to this step is to ask a health worker to present a talk on nutritional needs during and after diarrhea.

Step 3 (20 min)

Recommending Appropriate Diets for Children With Diarrhea

Divide the group into three small groups ((depending on overall group size) and give each group one child description based on Trainer Attachment 7E (Sample ChIId Description and Recommended Diet). Ask each group to recommend an appropriate diet for the child assigned to then.

Their recommendations should include'

- A description of the diet.

- Estimates of the cost of the food.

- Estimates of the required items to appropriately feed and care for the child in the manner they have described.

- An assessment of the cultural acceptability of the diet.

Tell the groups to they have 15 minutes to discuss the child description and record their recommendations on newsprint for large group sharing.

Trainer Note

Encourage the participants to be as detailed and exact as they can in describing the appropriate diet, including such information as' when the child should be fed, ho. much food. Also, encourage them to think about the practicality of their dietary suggestions, given food availability, food beliefs and preferences, who could be feeding the child (e.g., an older sister), other demands on their time, and so forth.

Step 3 (25 min)

Reporting on Nutritional Recommendations

Reconvene the group. Ask the small groups to present their nutritional recommendations following the format below. Allow about five minutes for each report. Be sure that each small group has a chance to report on one of their child descriptions.

- Ask the small group to read the child description aloud and post it.
- Ask them to post their nutritional suggestions below the description and explain why they recommend this particular diet.

After all the small groups have reported on one dietary recommendation each, have participants point out and discuss any recommendations which seem inappropriate or impractical.

Then ask the group to look at all the posted child descriptions and identify the child that is most likely to become seriously ill and possibly die. Ask them to explain this choice and predict what would happen if no nutritional interventions occurred. (If time allows, examine other cases similarly.)

Trainer Note

During the discussion, refer to the concept of the vicious circle of diarrhea and malnutrition.

Step 4 (20 min.)

Introducing the Counseling Activity

Facilitate a discussion of the techniques used during the nutrition counseling demonstration. Based on the discussion, make a list of "rules" for nutrition counseling. Ask someone to record this on newsprint for reference later in this step.

Divide into groups of three. Explain that the next activity will be practice in nutritional counseling and the format will be as follows:

- The group selects one of the child descriptions and recommendations from Step 3 and briefly discusses how to counsel the mother of this child.

- Each person in a group selects one of the following roles: mother of a sick child, health worker, observer.

- The health worker does practice counseling with the mother. The observer assesses how well the practice applies the rules for counseling and correct information about diet during and after diarrhea.

- The mother and the health worker comment on how they felt about playing their roles and the effectiveness of the counseling.

- The observer critiques the counseling practice.

- Members of the group change roles and repeat the counseling scenario, applying what they learned from the first practice.

Trainer Note

The "rules for counseling listed should include the following points;

- Show a concerned and caring attitude.

- Pay attention to building a good relationship.

- Listen carefully.

- Try to understand the problem as that person sees the problem (help them identify the problem; don't name it for them)

- Never persuade a person to accept your advice.

- Share information and resource ideas the person can use to solve the problem.

- Never share what the person tells you with others.

- Help people become aware of their feelings and cope with them (understand and accept a person's feelings; don't pity them).

Step 5 (45 min.)

Practice Counseling

Give participants time to carry out the activity. Circulate among the groups and contribute to the discussion and critique of the counseling.

Trainer Note

If possible, enlist the help of other Trainers or health counselors to help you facilitate the small group critique to assure that participants get adequate and accurate feedback on their counseling efforts

Step 6 (15 min)

Sharing Counseling Experiences

Reconvene the large group and have participants share problems encountered in counseling practice. Ask other participants to offer suggestions to overcome the problems. Close the session with a discussion of ways participants can apply what they have learned about diet during and after diarrhea and nutrition counseling techniques.

Handout 7A: The diarrhoea-malnutrition complex

The main mechanism by which diarrhoea leads to malnutrition is uncertain and few data exist to clarify the situation. Mike Rowland reports from a long-term study in The Gambia looking into this problem.

Diarrhoea and malnutrition are major causes of childhood morbidity and mortality in less-developed countries. the interaction between the two was highlighted during the early 1960's and an excellent account later published. The complex relationship is still not fully ater published. The complex relationship is still not fully understood but two generalizations appear valid.

Failure to thrive

Malnourished children (i.e. children who are failing to thrive) appear to suffer more severe episodes of diarrhoea than their better nourished counterparts and to excrete infective organisms for longer. This situation is complicated by the fact that impaired growth in many of these children may he largely due to the heavy burden of diarrhoea already experienced.

Diarrhoea more than any other infection causes serious growth-faltering in children in many areas of the world. It is significant that in the three continents where this has been well described all mothers in the study communities breastfed their children for long periods. The children would almost certainly have been worse off if fed otherwise but protection is not complete in most subjects nor does breastfeeding preclude serious morbidity in under-privileged communities.

Food shortage

Some workers feel that food shortage in the community plays a relatively minor role in early childhood growth-faltering and that if diarrhoea could be prevented near-normal growth could occur. The main mechanism by which diarrhoea leads to malnutrition is uncertain and few data exist to clarify the situation. Some suggest that anorexia is the main cause, others that malabsorption due to abnormalities of gut flora and function is a more likely explanation.

Seasonal variation

In The Gambia there is marked seasonal variation in growth and disease in young children and studies there have thrown some light on these problems.

At certain times of the year it appears that normal and even catch-up growth is possible on a traditional diet of locally grown food, provided the individual child suffers little diarrhoea. At other times of the year, however, growth is uniformly depressed whether or not diarrhoea occurs and this tends to be the case in the traditional "hungry season". Thus diarrhoea at different times appears to have an effect on growth of widely differing magnitude. Just as the aetiology may vary from season to season and also from one age-group to another, so may the nature and severity of the pathological processes which follow infection.

Malabsorption

In the Gambian community studied diarrhoea is certainly responsible for some reduction in complementary food intake in the weanling child (i.e. the child receiving troth breast milk and additional foods). hut so are a number of other infections which have little or no detectable effect on growth. Furthermore there tare indirect indications that some degree of intestinal malabsorption may be common in the young village children. On balance it appears that in this community at any rate malabsorption is more important than anorexia in explaining diarrhoea-induced growth-faltering.

Weanlings at risk

Whatever the mechanism it seems clear that the initiation of the weaning process, even when breastfeeding is continued for long periods afterwards, puts children at serious risk. This is supported by examination of the weaning foods used. In The gambia the earliest weaning foods are cereal gruels or paps. These are grossly inadequate nutritionally with approximately half the energy-density of breast milk and many of other nutrients are inadequate or totally lacking.

Furthermore it is these earliest foods which show the highest levels of bacterial contamination, both with faecal "marker" organisms and known gut pathogens. Local fuel shortages make it impossible for mothers to cook frequent meals for small children. Instead larger quantities are prepared and kept for long periods, when they may easily become contaminated.

A total approach

In this situation we cannot afford to neglect any health strategy including promotion and active support of the breastfeeding mother, the appropriately timed introduction of hygienically prepared, nutritious weaning foods, the general use of complete oral rehydration mixtures, and various aspects of environmental sanitation. In the course of treating children with diarrhoea, breastfeeding should be maintained and other foods withheld only if there appears to be clinically important intolerance (and not just malabsorption) to these foods.

We may hope for vaccines against a number of diarrhoeal agents in the near future but as title is known of the impact of various individual agents on growth in different communities it would be unwise to try to predict the efficacy of this stage is which, if any, organisms are part6icularly important in the diarrhoea-malnutrition complex; useful work is already being undertaken along these lines in Bangladesh.

Handout 7B: Carry on feeding

In communities where malnutrition la common, correct feeding is as important as rehydration for children who have diarrhoea We report on studies from Bangladesh illustrating this point.

A recent careful survey of young children in Bangladesh revealed that, on average, each child suffered 6.8 episodes of diarrhoea per year. Added up, this meant they had diarrhoea for 55 days or 15 per cent of the year). Such children will end up severely deprived of nourishment if they are starved all the time they have diarrhoea. Although digestion is less effective during diarrhoea, there is still a significant amount of absorption of nutrients. The Dhaka work has shown that, in children given as much ordinary food as they will take, the amount of protein absorbed is reduced to about 50 per cent, the amount of fats to 60 per cent and the amount of carbohydrate to 80 per cent. This fall in digestive efficiency varies to some extent with the cause and mechanism of the diarrhoea, but the figures show that, in spite of the disease, the children manage to absorb valuable amounts of essential nutrients.

Breastmilk - energy value

Another Bangladesh study compared the normal dietary intake of small children with diarrhoea with that of a group of matched controls. The energy intake of the ill children was reduced by 40 per cent, but among those children who were being breastfed; the energy intake from mother's milk showed very little decrease. This suggests that the loss of appetite is mainly associated with supplementary foods. Breast milk is therefore a particularly valuable nourishment for children with diarrhoea, especially among deprived communities where it may be the main source of high quality protein. Every effort ought to be made to continue breastfeeding during diarrhoea, not least because breastmilk supplies depend on the stimulus of sucking. If breastfeeding is interrupted every time diarrhoea occurs, there will soon be much less of this important food available for the child at the time of greatest need.

Which foods and when?

Despite recent studies, unanswered questions remain about what are the best foods to offer during diarrhoea and when to introduce them. In acute diarrhoea, most foods can be given safely and soon. In chronic diarrhoea, feeding may be more of a problem (ace Diarrhoea Dialogue 10 for Professor G. C. Cook's article on causes and control of chronic diarrhoea). Mother's milk is better tolerated than cow's milk and breastfeeding should continue during diarrhoea. Children with diarrhoea who are being bottlefed need to have the formula diluted with an equal volume of water while the diarrhoea continues.

The important point is to start giving small, frequent feeds of a familiar diet as soon as rehydration is complete, preferably mixed with a little extra vegetable oil to increase the energy content. Vitamin A supplementation is required in areas where xerophthalmia (night blindness) is common.

During convalescence after diarrhoea, children need extra food for 'catch-tip' growth. This can be given as nutritious snacks between meals or as an extra meal every day for several weeks.

Compiled by the Scientific Editors from information provided by A. and A. M. Molla, ICDDR, B, Dhaka, Bangladesh.

Handout 7C: Breast to family diet

Weanlings are particularly vulnerable to infection. Michael Gurney considers how this important time can be made safer and more beneficial for the baby.

Weaning does not refer only to the stopping of breastfeeding. It is the gradual process by which a baby becomes accustomed to semi-liquid and solid foods which increasingly complement breastfeeding. It is complete when the child is eating the regular family diet and breastfeeding has completely or nearly stopped. Phrases such as "the baby should be weaned at six months" can be very misleading.

Weaning is one of many changes that all take place together. The weanling child is becoming accustomed not only to new foods but to a new environment and to new physical and mental skills. He is very vulnerable to illness at this time.

When should weaning start?

The best way to wean varies according to the circumstances of each family. If a mother has to go out to work she may have to start giving extra foods earlier than is best for the baby, while continuing to breastfeed whenever she is at home. Where sanitation and cooking facilities are poor, she may be wise to start weaning foods later than is ideal.

In general, breastmilk is perfectly adequate until the baby is at least four to six months old, or weighs about seven kilograms. Other foods need to be introduced about this time to complement breast milk. They are unnecessary, and can be dangerous, if given earlier.

What makes a good weaning diet?

Texture: At first, the baby needs liquid foods. These become thicker until, by his first birthday, he is able to chew pieces of food. A good practice is to start with a porridge or pap containing the food ingredients mixed together into a creamy consistency.

Quantity: Babies have very small stomachs and are growing very fast. They need small amounts of foods which are rich in dietary energy. Little and often is the rule. At first weaning food is extra to breastfeeding; as time goes on it becomes the main food, and breastfeeding becomes less important. The frequency of feeding should increase rapidly until the baby is soon taking at least five meals a day plus breastmilk. Feeding should continue at this rate well into the baby's second year. Snacks, such as fruit, between meals are useful - as long as they are always clean.

Quality: Most weaning diets around the world are based on starchy staple foods such as rice, potatoes and cassava. This is fine as long as certain precautions are taken. Such staples are not nutritious enough in themselves. A porridge using the staple mixed with something extra is excellent. The best additions are peas and beans mashed with the skins removed; milk; meat (finely chopped) or other animal foods; plus dark green leafy vegetables or yellow-orange fruits such as papaya and mango. Suitable recipes and methods of preparing weaning mixes can be found and developed in most cultures.

Energy supplement: Many weaning porridges do not contain enough energy for the baby's needs. During cooking, the starch used in the porridge takes up water and becomes very bulky. Extra oil added to the porridge has two benefits: it adds energy (oil is very rich in calories); and the oil changes the consistency of the porridge, making it easier for the smallest babies to swallow. Oil should be incorporated in all weaning foods except where obesity is a problem.

Two other ways of reducing the bulkiness of weaning foods and making them better and easier for the infant are fermenting or roasting the staple grains. This is done in some parts of the world and can be of great benefit.

Economy: if people spend extra money to buy special weaning foods they are likely to give too little in order to make it last. Weaning foods made at home can be just as good as those bought from shops. In fact, some products sold for babies are very poor in nutritional quality. It is usually best to rely on foods available from the family pot.

Hygiene: Contaminated food is one of the most critical problems during the weaning period. In poor, unsanitary environments it is very difficult to avoid diarrhoea in young children. Breastfeeding provides a major protection against diarrhoea. Good hygiene is essential in preparing weaning foods and keeping them until the next feed. But it is difficult to feed a baby five or more uncontaminated meals a day, when the mother can only afford to light the kitchen fire once. Local technologies need to be used to resolve the problem.

Utensils: Bottles and rubber teats are difficult to keep clean. Moreover, in order for a weaning porridge to pass through the teat it has to be very dilute; therefore the baby risks not getting enough food. It is best to keep suckling from the breast, not the bottle. When food is mashed for a baby, avoid using sieves which are difficult to clean. A cup and spoon are suitable for giving weaning foods; this allows the mother to change the food from liquid to semisolid as the baby grows.

Breastfeeding: Breast milk is very nutritious and protects against infections. It also provides the close, loving contact that encourages secure development. As far as possible, breastfeeding should continue throughout the difficult process of weaning.

Dr Michael Gurney, Nutrition Unit, WHO, CH-1211 Geneva 27, Switzerland.

Handout 7D: Persuading children with diarrhoea to eat

Encouraging a child with diarrhoea to eat is a difficult and exhausting task for the mother. However, children should be encouraged to eat as early as possible during an attack.

Although rehydration is the most immediate and vital aspect of the management of diarrhoea, the giving of energy in some form of food is essential. In many parts of the world, people think it is necessary to starve children with diarrhoea. This is dangerous. Starving can start off malnutrition, or worsen it, making the child too weak to fight infection.

Extra meal

Food should be given to the child as soon as dehydration is corrected, any vomiting stops, and the appetite returns. Breast milk and other liquids (but not cows milk and infant forumla foods) should continue during oral rehydration. Once the diarrhoea has stopped, at least one extra meal should be given each day for a week if possible.

Small portions

Feed the child with small portions throughout the day. Do not force him to take too much food at a time. The composition of the food can be changed gradually until the child goes back to his normal solid diet. The motjher will know which food the child likes best and can further encourage his appetite by adding additional flavouring.

Every effort should be made to feed the children as there is evidence that even during diarrhoea as much as 60 per cent of nutrients are absorbed. In may developing countries, low-energy gruels from the basis of children's diets, and therefore the sick children has to eat much more to obtain sufficient calorie intakes. Try to give a child with diarrhoea a higher intake of energy foods (see Chart A). Mothers need to be shown how to use locally available foods to the best advantage to their children.

Other important points

· Try to prepare all food in a clean place, using clean pots and utensils.

· Food should be eaten soon after it is cooked. If not, it should be thoroughly heated again before eating.

· Wash uncooked food in clean water before eating.

· To be sure a young child is getting enough food, try to give him a separate plate or dish. The dish should have a cover.

Trainer Attachment 7A: Problem poster activity

Setting:

A community meet-leg or woman's group meeting to discuss prevention of health problems.

Preparation:

- Prepare two large posters - one depicting a malnourished child and the other depicting a healthy child

- Prepare two sets of small cards: one set has drawings of causes of malnutrition associated with diarrhea such as: a child with diarrhea defecating in the yard, a child refusing to eat during diarrhea, an unbalanced meal; a mother withholding food during diarrhea etc. The other set shows ways to prevent malnutrition resulting from diarrhea in children such as: feeding the child, a mother breast-feeding, using a latrine, washing hands etc.

- Tape the posters and cards on the wall or blackboard.

Procedure:

- Show the picture of the malnourished child and ask the participants, "how would you describe this child?.

- Show the poster of the health child and ask, "How would you describe this child?."

- Place all the small cards on a table and ask for volunteers, one at a time, to select a small card and place it next to one of the large posters and explain why he or she is placing it there.

- Have the group discuss these answers. Use this as a basis to discuss the vicious circle of diarrhea and malnutrition.

- Ask someone to draw a diagram showing how diarrhea and malnutrition interact.

- Ask the participants what could be done to break the vicious circle of malnutrition and diarrhea in their communities.

- Have them discuss ways they could use this activity in their communities.

Trainer Attachment 7B: Nutrition counseling demonstration

Setting:

The home of a woman with a child suffering from diarrhea. It is the rainy season and the food supply is limited, consisting mainly of starchy foods.

Use Case two on page 29 of Treatment of Diarrhoea for additional details of the setting and the case.

The health worker

You heard about the case from a neighbor visiting the health post. and decided to make a home visit. You want to counsel the mother about what to feed her child during and after this bout of diarrhea, following the WHO recommendations stated in Treatment of Diarrhoea on pages 4-6. Emphasize locally available foods and recognize local food practices and beliefs. Take great care to follow the rules for good counseling listed in the Trainer Note following Step 4, because participants will be using this demonstration as a model for their own counseling practice later in the session. You show the mother how to prepare oral rehydration solution and supplementary food using ingredients available in the home. You ask her to do a return demonstration to show that she understands what you have shown her.

The Mother

You are very concerned about your child. You are a traditional woman and have always followed the traditional practice of withholding food and liquid from your children when they have diarrhea. Your family has little land and the food stores are getting low because it is the rainy season.

Props needed

Chairs, table, local dress for the mother and white coat or hat for the health worker, doll or blanket "baby." utensils and ingredients for preparing the food.

Trainer Attachment 7C: Therapy begins at home

Careful exploration in each society will be needed to determine the most scientifically appropriate, culturally acceptable, and affordable household fluid mixture with which to start therapy at home. Breast milk is, of course, an excellent solution. White its protective effects are well recognized, I wonder if we have really fully explored its potential in the therapy of diarrhea. Clean, nutritious, and widely available to the age group of highest risk, six to twenty-four months, we need only to find ways of further increasing quantity on demand. Increased frequency of suckling during illness has already been documented. The additional milk rehydrates and nourishes as well.

While we can give an unqualified endorsement to breast milk. further investigation of potential home solutions are needed before they can be widely recommended. The studies of rice starch have used finely ground flour carefully stirred into hot water to facilitate dissolution. Preparation requires time, patience, and fuel. The solution becomes undrinkable within six to eight hours. Other starch or liquid nutrient mixes are even less well studied. Nonetheless. I remain confident that appropriate home remedies are out there waiting to be discovered, more widely used, and integrated into our therapeutic schema. Rice water, carrot soup, broths, or others may provide effective, cheap, believable, and universal antidotes to the world's biggest killer

Of equal importance to rehydration, and even more often neglected, is attention to feeding during convalescence, that brief period of a few days following illness when a recovered child has an increased appetite and will take even more food than normal. The phenomenon of catch-up growth or growth spurt following illness has been well documented for cases of severe malnutrition, endocrine disorders, and overwhelming systemic infection. While it is not yet well understood, such increased growth rate is possible in the immediate days following acute illness, provided adequate additional food is available Growth two, three, or even four times normal can make up for weight losses incurred during illness and bang the child back to his normal growth curve. This requires frequent feeding with readily digested foods administered throughout she day, almost as if on a prescription. But the opportunity is a brief and fleeting one. The small food supplements provided in most nutrition programs are just not enough. From 150% to 200% of Recommended Daily Allowance for three to five days is needed to capitalize on this growth potential. It appears that targeted use of food supplements providing intensive feeding for only several days following diarrhea may be a major intervention strategy in the nutrition infection interaction Food is an integral part of the oral therapy strategy without it we accomplish little more than a delay in mortality With food comes the prospect of improved health and quality survival.

All of this depends on the critical understanding and willingness of mothers to treat every diarrhea episode in her child as important, with early and aggressive use of appropriate fluids and nutrients available to her in her home. i low do we reach the mother? How do we penetrate the ignorance and misinformation surrounding diarrhea? How do we work together?

First, it is our ignorance more than that of mothers that has led to failure, our ignorance of how they perceive illness and health. of causality and reasonable responses. Diarrhea is often not considered an illness, not life threatening but a healthy cleansing of the body Fluids cause more diarrhea; intestines need a rest; food cannot be digested; and so on. Only by understanding their concepts, beliefs. and practices can we tailor our communication approach to build upon what mothers know, a better understanding and acceptance of the whets and whys of diarrhea management Too often what we say just does not make sense.

Mothers, on the other hand. need to understand some facts, too: what diarrhea is, how it leads to malnutrition and occasionally death, why fluid and nutrients given by mouth save lives, how extra feeding for even a few days hastens recovery. We cannot expect blind acceptance of our instructions which, more often than not, fly in the face of every tradition and logical response they know. We need to listen to and understand each other

Second, is our attitude towards mothers. We must recognize each mother for what she is: the person most vitally concerned about her child's health, but, even more, a valued and important member of the health team. We must treat her as other health workers, informing her in an appropriate and respectful way. She must see for herself and learn by experience. as ail of us have done in this field. Our approach must therefore be a collegial one, addressed to her capacity, but constantly involving her in the active learning process. It is the mother who must treat her child, whether in the hospital, in the health renter, outpatient department, community or home. We must demonstrate in a patient and effective fashion the precise activities that we expect from her do assess, the we do during the training of any other health worker, her understanding and capability of accepting and carrying out this skills. Competency-based experiential training is the key. The classical approach of haranguing mothers in a crowded, noisy, hot waiting room with an unfocused and boring lecture is no substitute for the personal approach and demonstration of how the mother should handle diarrhea in the home.

Third, it may come as a surprise to many of us caught up in She enthusiasm for the role d mothers that fathers are often intimately involved in the decisions affecting childrearing, especially during illness. From the Bangladesh Rural Advancement Committee (BRAC) we will hear that although Bangladesh mothers could clearly recall the proper formula for mixing home sugar/salt solution, only following special efforts to inform fathers about early home rehydration was the treatment widely accepted and used. Let us not forget that in some societies men still have a role in decision making.

Fourth, is our approach to information dissemination Modern communication techniques are used throughout the developing world to sell useless and often even harmful products. These same techniques, in the hands of skilled professional marketing experts, can introduce behavioural change leading to widespread adoption of the home oral therapy strategy in The Gambia and Honduras, following well-established market research procedures, culturally sensitive messages were widely disseminated through a variety of mass media. Knowledge and use of oral rehydration rose from less than 3% of mothers to over SO% in one year.

Social marketing is a complex process, much more than a few billboards and a radio jingle. As professionals in health, we must appreciate the unique professional qualities required d our colleagues involved in mass marketing, calling upon experienced firms to assist us. Together we must start with a comprehensive understanding of presently held beliefs and practice in order to assure the communication strategy is believable and acceptable in a given cultural-context. We must be precise and clear about the product or message that we err trying to sell, building on what is known and believed and changing accepted approaches only when they are unequivocally harmful. We must neither belittle nor ignore traditional culture or wisdoms. We must present our product in a believable and attractive way, convincing people that the home approach to rehydration and nutritional therapy for diarrhea is in no way a second-class therapy, but is rather a first-class response to the biggest threat to health in the world. It is, in fact the only workable response, and its elements must be clearly understood by all. Weoveramplify - the must not overamplify - the ORT approach is a comprehensive home nutrition strategy Rehydration with appropriate nutrient mixes, early refeeding, and added attention to nutrition during, convalescence are all integral parts d the oral therapy message without which we can expect little more than attenuation of the deaths occurring from diarrhea.

We must be sure that we have a consistent message, one that is reinforced in a coordinated way at all levels d our system. Somehow we must demonstrate to our doctors and nurses that ORT is technically effective. We must bury this strange, unfounded, yet deep-rooted belief among, medical professionals, of resting the gut - resting gut rapidly atrophies, enzyme levels fall, absorption worsens. Yet in the so-called "advanced medical centers" of the United States, children continue to be exposed to the costly an< unnecessary risks of intravenous infusions, while intestinal mucosa atrophies under the strict doctors orders of NPO (Nothing, by Mouth Until the medical profession understands, accounts, and practices oral therapy, can we expect others to embrace it? Where these professionals have been bypassed, failure has been almost universal. From Haiti, Indonesia, Jamaica, Costa Rica, and others, we will hear the important role that doctors can and must play to make the "mother strategy" a success.

Trainer Attachment 7D: Enriched ORT

Bert Hirschhorn considers the nutritional value of oral rehydration therapy.

Mothers and doctors alike have long believed that to feed a child with diarrhoea makes the condition worse. Those who insisted that malnourished children ought not to he starved did so apologetically, accepting a lesser risk. Now we ate told that continued feeding is good even for the adequately nourished. Why such a change in advice? It was oral rehydration therapy (ORT) with the full formula that made this feeding possible. Contrast the considerations before and after ORT was introduced:

Before	After
1. A child with diarrhoea feels sick and loses its appetite	1. ORT reduces nausea and vomiting and restores appetite*, partly through rapid correction of acidosis, hypotension and potassium losses
2. Food, especially milk, increases diarrhoea through osmotic fluid loss due to incomplete digestion after damage to intestinal enzymes.	2. Glucose-salt solution given as well as milk increases absorption and decreases osmotic fluid loss.
3. If food is withheld, diarrhoea was thought to slow or stop. (This was only partly true, for diarrhoea results from intestinal secretion which occurs independently of the digestion of food.)	3. With easy and rapid replacement of fluid loss by ORT, we are less concerned about stopping the diarrhoea immediately. Food is needed for recovery and to stimulate digestive juices and enzymes.

So now we can feed during diarrhoea and protect children from under-nutrition, without apologies.

Another use for foods

In the course of clinical experience, however, another use for food has been suggested. As early as 1971, after initial rehydration of American Indian children suffering with diarrhoea, an artificial milk formula made up from starch, glucose, casein, with medium chain fats and electrolytes. could maintain fluid and electrolyte balance in spite of continuing losses. The formula was effective, despite being hypertonic and with a large imbalance between sodium and glucose concentrations, conditions normally causing more diarrhoea and fluid loss.

Modern understanding of intestinal physiology suggests that it was the addition of casein (milk protein) that made the difference. Casein is easily digested to tri- and di-peptides and amino acids. Each of these molecule types stimulates sodium and water absorption by pathways across the intestinal cell membrane which differ from pathways for glucose. Moreover, peptides, and amino acids are more easily digested than sugars if the intestine is damaged by diarrhoea or malnutrition children with kwashiorkor are known to have less diarrhoea or malnutrition when fed a glucose-starch-casein formula.

Combining electrolytes with foods

Several recent clinical teals of enriched oral rehydration fluids have combined a sugar and an amino acid (glucose and glycine), or starch and protein (rice powder and breastmilk) with electrolytes. In each study, stool output was actually reduced by about half and duration of diarrhoea shortened by one third. This is just what mothers and doctors have always wanted: a treatment that prevents dehydration, reduces stool output and, at the same time, provides the nourishment to hasten recovery. Certain foods, in an enriched ORT, may turn out to be superior to antisecretory drugs, and have the advantage of being found in the home and not in the pharmacy. Research on optimal food-electrolyte combinations is now underway.

Trainer Attachment 7E: Child description and recommended diet

Prior to this session, the trainer should develop three to four descriptions of infants or young children under five for Step 3.

Make certain that the infant and child descriptions you create are significantly different, particularly in age and nutritional cultural practices that would affect that age of individual. Also be sure the descriptions are related to diarrhea so that participants have the chance to practice developing appropriate diets for children susceptible to, suffering from, or recovering from diarrhea.

The descriptions must include the followings his/her name, age, ethnic group or religion (If appropriate), season of occurrence, any relevant medical or social history, physical appearance, current health condition (weight, height and body temperature are optional pieces of information for inclusion).

Use the example given below as a model for writing the children's descriptions:

Child Description for Nutritional Description Exercise

Hawa is a 1 1/2 year old girl. She is a Moslem. It is the middle of Ramadan this year. She is very thin except for her big belly. Her mother has Just had another baby whom she is breast feeding. Hawa has a five year old sister, Adama, with whom she shares food. Adama helps her mother care for the younger children and has told her mother that Hawa has had "poopoo" five times today.

Suggestions for a Diet for Hawa

After you have written the child descriptions you should also write expected answers for the dietary prescription of the children. These "prescriptions" should not be considered to be the only acceptable answers, but possible ones. Be sure to take seasonal variations of foods into account when writing the dietary prescription expected.

In suggesting a diet for Hawa the health worker should:

- Use the WHO or country specific diarrheal assessment and treatment chart to assess Hawa's diarrhea and select a treatment plan.

- Take into account the host country's traditional feeding practices for an 18 month old child.

- With no further information available ( le. how many stools a day is normal for Hawa, is her pulse faster than normal, is she irritable etc.) other than the fact that she has five loose stools a day, the health worker should suggest that she be treated with ORS solution for rehydration and continue breastfeeding. When Hawa is rehydrated provide small amounts of multimix preparation.

It should be noted that the dietary prescription given for this example will vary from country to country depending on the availability of food and acceptability the child's age.

Session 8 - Recognizing malnutrition

TOTAL TIME

2 hours

OVERVIEW

In Session 7, participants discussed the "vicious circle" of diarrhea, malnutrition and disease leading from one to another, weakening and leading to death of the child if the circle is not broken. An important complement to prevention and control of diarrheal diseases is the identification and treatment of children who are at "high risk" for malnutrition and nutritional deficiencies. These weakened children are likewise susceptable to repeated cases of diarrhea and other illnesses. In this session, participants use pictures or slides to identify "symptoms" of malnutrition as well as the social indicators of "at risk" children. Later the group discusses growth measurement as a way of assessing children's nutritional status. In optional activities, participants practice weighing and measuring children and using and interpreting growth charts.

OBJECTIVES

· To recognize the signs and symptoms of children at high risk for malnutrition and diseases.
(Step 1)

· To use and interpret the Road to Health Chart. (Steps 4, 5)

· To use and interpret the anthropometric measures for identifications of "at risk" children.
(Steps 3, 6, 7)

RESOURCES

- Pediatric Priorities in the Developing World (Chapter 9).
- Guidelines for Training Community Health Workers in Nutrition (Chapter 2)
- Helping Health Workers Learn (Chapter 25, pp. 7-23.)
- Technical Health Training Manual (Peace Corps)

Handouts:

- 8A Growth Chart (to be obtained from the country health system)
- 8B Weight For Height Chart
- 8C Weight For Age Chart
- 8D How To Measure Weight-for-Length
- 8E Recording Weight on a Growth Chart
- 8F Measures Recording Sheet

Trainers Attachments:

- 8A Comparison of Measures
- 8B Monitoring Growth
- 8C Growth Chart Exercise

MATERIALS

Slides or pictures of malnourished children, slide projector, newsprint, markers, scales, arm circumference tapes, dolls, tape measures or meter sticks, weight for length board (see Handout 8D for instructions).

PROCEDURE

Trainer Note

It is assumed that participants have a basic understanding of malnutrition and have seen actual cases in their communities. If they lack this background, use the Trainer Attachments in Session 29 (Recognizing Malnutrition) in the Technical Health Training Manual to provide additional background. There are also optional steps at the end of this session Procedure section which you can use as more practice for the techniques covered in this session. Participants should understand that this session is only an overview of these techniques. Participants need practice to master them.

Before the session, learn as much as possible about the prevalent nutritional deficiencies in the country and be prepared to discuss them thoroughly. Prepare a vocabulary list of words in the local language describing these conditions.

Make sure the slides or visual aids you prepare for Step 1 allow participants the opportunity to see and identify specific signs and symptoms of various kinds and stages of malnutrition and nutritional deficiencies that are common in the country.

Ask a local health worker and a participant who has had experience in weighing children and using growth charts to help you prepare and conduct the demonstrations in Steps 3 and 4 and the optional activities. In preparation for this use Handout 29A (How do you Measure Malnutrition?), from Session 29 (Recognizing Malnutrition), Technical Health Training Manual, and information from Helping Health Workers Learn, Chapter 25, pages 7-16.

Obtain copies of the growth chart used in the country's health system and arm circumference tapes for each participant,

Prepare large versions of the growth charts using local data or the information in Trainer Attachment 8B (Monitoring Growth). Be sure to use cases including bouts of diarrhea. Also prepare one large growth chart with no measurements recorded.

Arrange with parents to bring a few children, from local families or Peace Corps staff, to the session for demonstration and practice of the measurement techniques. You could combine this with a health education activity for parents and children. An alternative is to hold the session in a local health clinic that weighs and measures children.

Step 1 (15 min.)

Recognizing MaInutrition

Using pictures or slides, ask the participants to identify and discuss the physical signs of the various forms of malnutrition they have observed in their communities and name them if they can. Suggest that participants assess malnutrition starting at the head and working down to the feet of a child.

Conclude this step by stating that while the group has Just reviewed pictures that represent various signs of severe malnutrition, the primary focus of the session is to provide participants with the necessary skills and knowledge to identify children at risk of developing severe forms of maInutrition.

Trainer Note

The following points may be included in the discussion on signs and symptoms of malnutrition. You may also want to add others. General symptoms of malnutrition:

- Hair-lighter colored, sparse, falls out easily, breaks easily, loses its shine

- Eyes-pale membranes (anemia); bubbly spot on white of eye indicates vitamin A deficiency

- Inner lower lip and tongue-pale membranes

- Upper arms-very thin

- Skin-patches of different color, very dry (these signs are easy to confuse with adverse environmental conditions or poor hygiene)

- Feet and ankles-swollen (edema): see if a mark remains after pushing finger in for a few seconds (also may see this in pregnant women)

(All the above signs are nonspecific and should not be used to diagnose malnutrition but to indicate that a problem may exist.)

Step 2 (15 min)

Identifying "At Risk" Children

Briefly explain what is meant by "at risk" children. Discuss the importance of monitoring their growth in terms of the effects that diarrhea and other diseases will have on their health status, if interviews are not taken early to prevent or treat these diseases.

Ask participants to recall situations they have observed in their communities where children were sick and malnourished. Ask them to think of physical signs and social conditions associated with these children. Brainstorm a list of social and physical signs that they could use to identify children at risk.

Have the group identify which of the risk factors from their list may be most significant in their communities.

Trainer Note

High-risk groups are usually children between the ages of six months and three years, and women who are pregnant or lactating. The following indicators which can be used to identify "at risk" children should be mentioned:

- Maternal weight below 43.5 kg.

- All birth orders over seven - Breakdown of marriage or death of either parent - More than four sibling deaths

- Birth weights below 2.4 kg. for males and 2.3 kg. for females.

- Failure to gain 0.5 kg. a month in the first three months of life and 0.25 kg. In the second three months of life.

- Breast infections and difficulties in breast feeding.

- An episode of measles, whooping cough and severe repeated diarrhea in the early months of life.

Emphasize the importance of careful observation as well as taking physical measurements to assess the nutritional status of a child.

For specific details concerning these factors, refer to See How They Grow (Chapter 9) or Pediatric Priorities in the Developing World (Chapter 9). WHO Guidelines for Training Community Health Workers in Nutrition discusses in simple terms the relationship between diarrhea and dehydration.

Step 3 (50 min.)

Assessing Nutritional Status

Begin this step by facilitating a discussion of the relationship between growth and nutrition. Tell the participants that monitoring a child's growth is one way of assessing his or her health and nutritional status.

Demonstrate the use of the arm circumference band, weighing and measuring length and height by measuring several children from the local community or Peace Corps staff. Record their measurements on newsprint. Distribute Handout 8B (Weight for Height) and 8C (Weight for Age) and ask the participants to use these charts to interpret the recorded information.

Ask at least one participant to do a return demonstration of each technique. Use Trainer Attachment 8A (Comparison of Measures) to discuss some of the limits of and distinctions between the measures and to cite the advantages and disadvantages of having a few discrete measures with which to assess a child's nutritional status.

Distribute Handout 8D (How to Measure Weight for Length) for their future reference.

Trainer Note

Be sure participants recognize the difference between the levels of information provided and uses for the arm band, the weight-for-age and the weight-for-height (or length) measures.

When discussing age-for-weight, briefly mention various ways that the health worker can determine a child's age. Several methods that can be used are:

- birth certificate
- developing a local events calendar
- counting the number of teeth the child has, and
- noting other developmental characteristics to estimate age.

See Guidelines for Training Community Health Workers (WHO), pages 23-24 on Nutrition for further discussion of estimating age.

If possible, it is important to use the optional step (Assessing and Iinterpreting Nutritional Status) to give participants practice in these techniques.

Step 4 (30 min.)

Introducing the Growth Chart

Introduce this step by noting that because growth and health status are not static, monitoring of growth should be a continual process of weighing, observing and systematic recording. This permits the health worker or parent to detect early signs of growth failure and hence high risk for illness and death. Distribute a blank copy of Handout 8A (Growth Chart) to all the participants.

Show a large version of a growth chart from Trainer Attachment 88 (Monitoring Growth) or from charts used locally. Explain the chart to the participants by pointing to the parts of the chart as you discuss them and stating:

- A child's age in months is listed in a column at the left side of the chart; the months are filled in across the bottom of the chart.

- The upper line on the chart shows the weight of well-fed children.

- The lower line indicates the area below which a child weighs less than they should for their age.

- The space between the line is the road to health and life.

- A child's growth curve should always be rising, if it isn't, this indicates that the child is in danger no matter where the child is on the chart.

Point to the place on the chart where the child had diarrhea and discuss the effect of diarrhea on growth.

Use the data collected in Step 3 or one of the exercises in Trainer Attachment 8C (Growth Chart Exercises) to demonstrate how to fill in the growth chart and interpret it. Use another exercise, and ask a participant to fill in the chart, with suggestions from the rest of the group. Ask the group to interpret the chart.

Distribute Handout 8E (Recording Weight on a Growth Chart) as a reference. Trainer Note

If time allows, it is important to use the optional step, "Using Growth Charts", after this step to give participants practice.

Step 4 (20 min.)

Discussing Problems and Applications of Measures For Assessing Nutritional Status

Ask the participants to review the growth chart and to list the different purposes that it can serve in preventing malnutrition associated with diarrhea. Ask for a volunteer to write their statements on newsprint.

Also discuss problems associated with using the various measurement techniques, interpreting the growth chart and teaching mothers to understand the chart. Close the session with a discussion of the possible uses of growth monitoring by participants to break the vicious circle of diarrhea, malnutrition and disease.

Trainer Note

Reemphasize the point made in Step 3 that measuring growth is a means to monitor nutritional status. Several purposes the chart serves include:

- Keeping pertinent and concise medical records on children during critical developmental stages,
- Encouraging mothers' ongoing involvement with an Under-Fives' clinic,
- Providing a quick visual means of monitoring a child's medical history for untrained workers,
- Charting a child's age and appropriate times for immunizations,
- Having a record of the health history for different health personnel if the child moves.

Some of the points that should be mentioned or discussed concerning the use and importance of the growth chart are:

- If a child is growing well he or she is probably healthy and adequately nourished. Months before a child has obvious signs of malnutrition, he or she will have stopped growing

- Growth is measured in several ways and baby weight is the simplest.

- The health worker may have difficulty getting correct age from mother.

- The mother or health worker may have difficulty in accurately charting the weights. (e.g. Individuals may use January-December calendar rather than the child's birth calendar),

- Individuals can become so involved in completing the chart that they forget to look at the child, analyze the data or discuss the child's progress with the mother.

- Host Country Nationals may feel that the standards used in developing the growth lines are not appropriate for their population.

Make sure the group understands the relationship between growth and nutrition as well as the relationship between diarrhea and growth as discussed in Session 7 (Nutrition During and After Diarrhea).

Optional Step (90 min)

Assessing and Interpreting Nutritional Status

Tell participants they will be practicing measurement techniques in this activity. Form small groups of two or three persons, and distribute Handout 8F (Measures Recording Sheet). Demonstrate how to record information on the sheet. Stress the importance of recording each measurement immediately, to reduce errors in measurement. Encourage them to be as accurate as possible.

Assign specific groups to the work stations and have them take turns weighing children, measuring their height/length and measuring their arm circumference. Ask them to record these measurements on Handout 8F and talk with the parents to establish the children's ages and general health history.

When groups have finished measuring the children and recording the data, have them spend a few minutes discussing the individual measurements for the various children, referring to Handouts 8B (Weight For Height), 8C (Weight for Age Chart), and page 44, "Use of the Colored Arm Strip" in the Treatment of Diarrhoea. Thank the community members again for their help in the training program.

Reconvene the group and have each small group report on the information for the various children they measured. Ask a participant record this information on newsprint and compare the variations in measurements within the small groups with the variations among the small groups. Have the groups discuss any difficulties they may have had in doing the measurements. They should also briefly discuss the problems encountered and identify any additional information or skills they need.

End the activity by asking each participant a skill or attitude needed for monitoring growth.

Trainer Note

Prior to this activity, set up work stations with measuring and weighing equipment that is available in the local area.

This step will vary slightly depending on whether the trainer was able to arrange for local infants and children to come in to be measured or, preferably, to visit an Under-Fives Clinic. If children are coming in, the trainer should explain to the group that this is a real opportunity to do some nutrition counseling and to apply the health education information they have already learned. When the families arrive, the trainer should welcome them and thank them for helping the training effort. Explain the purpose of the measuring tasks and what procedures will follow. Avoid overwhelming any infant or child with many strangers at one time. Make sure the child is not measured by more than two small groups using the same techniques. You may wish to have participants assess children for other clinical signs and symptoms, (e.g. Vitamin A deficiency, anemia, etc.).

If time permits you may also wish to have participants discuss the accuracy of different local weighing and measuring tools or consider making of some of the measuring devices themselves in their sites. Helping Health Workers Learn (Chapter 16, pages 1-2) includes information on making simple measurement equipment. Handout 8D shows how to make a measuring board.

Optional Step (40 min.)

Using Growth Charts

Ask individuals to form pairs and spend 20 minutes filling in the charts using the information posted. Also ask them to interpret the health status of the child.

After 10 minutes ask one pair to present their assessment of the child's health.

After the presentation have the other participants add additional comments, evaluate the assessment and state whether they agree or disagree with the diagnosis and why.

Ask the group to discuss any difficulties they had in using the chart and to identify the benefit and drawbacks to using it as an assessment tool.

Trainer Note

For this activity use Trainer Attachment 8C (Growth Chart Exercise) or data from the local citric. Post this on the vail or duplicate the information for each person and have them plot it on Handout 8A (Growth Chart). Make a large version of a correctly filled in chart to use during the discussion.

Handout 8B: Weight for height (stature) for both boys and girls

DIRECTIONS FOR MEASURING CHILDREN WHO ARE 85 CM OR MORE IN HEIGHT

Step 1. Place the measuring board in a verticle position on a flat surface

Step 2. Have the mother (or assistant) remove any footwear or headgear on the child and lead the child to the measuring board.

Slap 3. Place the child so that the shoulder blades bullocks and heels are touching the vertical surface of the measuring board. The feet must be flat on the floor slightly apart teas and back straight and arms at sides. The shoulders must be relaxed and in contact with the measuring board The head usually is not in contact with the measuring board. Tell the child to stand "straight and tall" and look straight ahead

Slap 4. One assistant (the recorder) checks that the child elands flat fooled with the knees fully extended The shoulders and bullocks should be in line with the heels

Step 5. The movable headboard is then brought to test firmly on the crown of the child's head by the measurer while the head is held so that the child's eyes point straight ahead

Step 6. The measurer reads the measurement to the nearest 0.5 cm.

Step 7. The recorder then writes the measurement clearly on the form.

Step 8. The measurer then looks at the recorded value on the form to be sure that it is correct.

Handout 8C: Weight for age chart

Handout 8D: How to measure weight-for-length

Make a measuring board

You can make a measuring board like this:

1. Buy a meter-long measuring stick at a bookstore or hardware store.

2. Get a piece of plywood 1/2 to 1 cm thick. Cut it in 3 pieces:

- 15 cm x 15 cm (Headboard)
- 15 cm x 40 cm (Backboard)
- 15 cm x 20 cm (Footboard)

3. From another piece of wood, about 5 cm thick, cut a triangular block 15 cm x 6 cm.

4. Attach the meter stick, backboard, triangular block, and headboard as shown in the drawing. Use small screws. (The footboard stays separate and is not attached to the other pieces.)

5. Since the backboard will be rough (because of the meter stick and the screws), you can cover the backboard with a cloth, to make the children comfortable.

WEIGHT FOR LENGTH (Supine) FOR BOTH BOYS AND GIRLS

DIRECTIONS FOR MEASURING CHILDREN WHO ARE LESS THAN 85 CM IN LENGTH

Step 1. The measuring board is placed horizontally on the ground or on a table

Step 2. With the help of one or two assistants place the baby barefoot and without head covering on the measuring board with the head against the fixed (non-movable) end

Step 3. An assistant holds the baby's head so that the eyes are pointed straight up and applies gentle traction to bring the top of the child's head info contact with the fixed end of the measuring board

Step 4. The measurer holds the child's knees together and pushes them down against the tabletop with one hand or forearm, fully extending the child. With the other hand the measurer slides the movable footboard to the child's feet until the heeds of both feet touch the footboard.

Slop 5. The measurer then immediately removes the child s feet from contacts fact with the footboard with one hand (to prevent the child born kicking and moving the footboard) while holding the footboard securely in place with the other hand.

Step 6. The measurer reads the measure meat to the nearest 0 5 cm.

Step 7. The recorder then writes the measurement clearly on the form

Step 8. The measurer then looks al the recorded value on The term to be sure that it is correct.

Handout 8E: Recording the weight on a growth chart

Recording weights on the growth chart

The weight of a child should be recorded on the chart according to the instructions given below.

1. Write the name, address, and other information about the child and the family on the back of the chart. It is important to do this at once to show whose record this is and to avoid recording one child's weight on another child's chart.

2. Write the month of birth in the box below the first vertical column (the first box which has thick lines around it). Near the box write the year of birth. This is September 1978 in the example shown in Fig. 7.

3. Note that there are 5 sets of 12 columns. Each set is for one year of the child's life. Beginning with the month of birth (see instruction 2), write out the following months of the year in the following boxes. When you reach January, write the year near that box exactly as you wrote the year of birth (see instruction 2) near the box for the month of birth.

4. Record the weight by putting a big dot on the line corresponding to that weight in kilograms. For example, if the weight of a child is 6 kg in a given month, find the horizontal line representing 6 kg and put a dot at the point on that line where it meets the column for the month in which the weight is being taken. This is January 1979 in the example shown in Fig. 7.

5. The position of the dot within a column can be adjusted. The purpose of this is to indicate when (early in the month, in the middle of the month, or late in the month) the child is being weighed. If the child is being weighed early in the month, put the dot towards the left side of the column. Put the dot in the middle of the column if the weight is being taken in the middle of the month. If the weight is being taken late in the month, put the dot towards the right side of the column.

The above instructions should be followed each time you record the weight on a chart. An example of a weight-chart showing 3 weights of a child taken on 3 different occasions is shown in Fig. 8. Notice that the three weight dots are joined by a line. This is the line of growth. It is very important.

Notice too, that the chart in Fig. 8 is for a different child from the one in Pig. 7. The child in Fig. 8 was first seen and weighed in September 1987 by the community health worker, who questioned the mother about when the child was born. The month of birth (June 1977) was written in the first box on the chart and the first weight record was placed in the fourth column (September).

Handout 8F: Measures recording sheet

Trainer Attachment 8A: Comparison of anthropometric measures

Trainer Attachment 8B: Growth monitoring

The charts shown here are reproduced from the actual growth charts of individual children. Around the edges of the charts - and on the reverse side - there are panels of advice on other aspects of child's health- e.g. immunization records and reminders, advice on when and how to use oral rehydration therapy, and messages about breastfeeding and weaning.

The child who's growth is depicted on this chart made good progress, despite set-backs at the time of coming off the breast and after a bout of measles. Weight loss was not allowed to continue once it had been detected by the chart.

This child a boy also grew quite well for a year. But then measles, diarrhoea, bronchitis and whooping cough struck in quick succession. Wit no time for recovery inbetween each bout of illness and weight loss, the sheer frequency of the set-backs finally proved too much and the boy died half-way through his second year The cause of death was recorded as 'whooping cough' But as the chart shows the real cause was the combination of infection and malnutrition, each reinforcing the other

This child progressed well unlit coming off the breast al about 18 months of age. Soon afterwards, she developed measles and lost more than a quarter of her body weight Part of the weight loss was caused by dehydration. Without a growth chart, this serious setback might have gone un-noticed. As it was, extra feeding helped a satisfactory recovery and a rapid making-up of growth (original chart in Spanish)

Trainer Attachment 8C: Growth chart exercise

Give one of these examples or ones that you have collected from local records, to the group for plotting and interpretation. Make a large version of the correct form to shot. when participants complete the activity.

A girl was born in May 1976. Her name is Laxmi. She was weighed on different months following her birth. The weights in each of the months are given below.

The following weights are for Jose who is the first and only child of a couple who have been married 10 years. Jose has only been bottle fed. He was born in February of 1975.

Session 9 - Preventing malnutrition

TOTAL TIME

2 hours, 30 minutes

OVERVIEW

In the session on "Nutritional Needs During and after Diarrhea" participants discussed special nutritional problems faced by children with diarrhea and learned about appropriate feeding during and after diarrhea. In this session, participants focus on interventions for children "at risk" for malnutrition and disease. Participants examine the causes and conditions which underlie malnutrition, and use this understanding to develop specific health education plans for the prevention of malnutrition through efforts in the health center, the family and the community. The session includes optional activities on nutritional rehabilitation and preparing multimixes.

OBJECTIVES

· To recognize and describe the chain of events leading to malnutrition.
(Steps 1, 2)

· To identify and discuss possible strategies for preventing malnutrition.
(Step 3)

· To develop and present a health education plan that promotes good nutrition.
(Steps 4, 5)

· To explain the basic principles and methodology of nutritional rehabilitation.
(Optional)

· To prepare multimix weaning foods in the proper proportions.
(Optional)

RESOURCES

- Helping Health Workers Learn. Chapter 25
- Nutrition Rehabilitation , its Practical Application.
- Bridging the Gap

Handout:

- 19D Session Plan Worksheet (From Session 19)
- 9A Multimixes as Village Level Weaning Foods

Trainer Attachments:

- 9A Story of All
- 9B Case Studies
- 9C Nutritional Rehabilitation Centers
- 9D Guide for Multimix Preparation Stations

MATERIALS

Newsprint, markers, see Trainer Attachment 9D for materials needed to prepare multimixes.

PROCEDURE

Trainer Note

Participants should be asked to bring to this session information they gathered and analyzed during their visits to the community (Session 13 - The Impact of Diarrhea on Culture) and notes from other training sessions that you think would help them identify underlying factors which may affect a child's nutritional status.

Since they will also be asked to design a health education activity, this session should be used after Sessions 16 (Selecting and Using Nonformal Education Techniques) and 19 (Designing and Evaluating a Health Education Session.

Step 1 (15 min.)

Identifying the Conditions Which Underlie Malnutrition

To introduce the session, post and read the definition of "Causal Chain" and "Causal Web" stated in the Trainer Note below, to the group. Give a few examples to illustrate each concept. Ask the participants to discuss these concepts and ask any questions they have.

Tell the participants that in this step you will read them a story and they should listen and identify the causes (chains and webs) of hunger and nutrition mentioned in this story. After the story you will play a game and apply the concepts of chains and webs. Read the story adapted from Trainer Attachment 9A (Story of All).

Trainer Note

The definitions for "causal chain" and "causal web" are:

Causal Chain can be considered "a chain of events leading to disease or III health". It is a micro way of viewing a health problem. (Examples: bottle feeding, diarrhea, abrupt weaning)

Causal Web may be defined as "all the underlying factors contributing to and enhancing the disease sate". It looks at a health problem from a macro perspective. (Examples: poverty, inadequate medical care, population pressure.)

Step 2 (20 min.)

Processing The Story

Play the game called "Another One. as a way to stimulate discussion of the many related causes of hunger and nutrition. Mention that this is a training activity the participants can use at their work sites as well.

Tell the participants that you will ask them a question based on what they remember from the story that you have Just read. They are to give an answer to that question and then "another one" and "another one". Ask two participants to write the answers given under two headings "causal chains" and "causal webs". Assign one heeding to each recorder.

Play the game "Another One". After the participants have generated as many answers as they can, have the group review the lists as well as the information they obtained from previous sessions and their visits to the community and address these questions:

- Are the items listed under the correct headings"
- What are other causes or underlying factors that have not been considered? (Please list)
- Which of the factors listed are most relevant to your programs and community? (Please circle)

Trainer Note

The list of factors related to malnutrition may include:

Chain Factor	Web Factors
· Low birth weight	· Inequitable food distribution
· Bottle feeding	· Insufficient food production
· Abrupt weaning	· Poor utilization of available food
· Parasitic infections	· Poverty
· Lack of medical care	· Infections compounding malnutrition
· Lack of sufficient protein/calories in the diet	· Inadequate medical care
· Dehydration	· Traditional beliefs/practices (e.g. food taboos)
· Diarrhea	· Population pressures
· Measles	· Poor climate for growing food
· Malaria
· Wastage due to pests
· Low priority of health/nutrition
· Insufficient preservation of foods

Emphasize the concept of the vicious circle of diarrhea and malnutrition discussed in Session 7 (Nutrition During and After Diarrhea) also refer back to the larger causal circle discussed in Session 3, (Preventing and Controlling Diarrheal Diseases). Step 3 (20 min.)

Identifying Strategies for Preventing Malnutrition

Based on the list of factors the participants have identified as most relevant to their programs, ask the participants to identify:

- strategies for preventing malnutrition
- realistic ways PCV's could intervene in any of these factors to prevent malnutrition
- ways to involve mothers, local health workers, health officials, etc.

Trainer Note

Write the answers to some of the questions on newsprint as the participants state them. List the strategies for preventing malnutrition next to the list of causal factors. Some strategies for preventing malnutrition include:

- Nutrition education
- Promotion of breastfeeding
- Use of nutritional weaning foods as a supplement to breast feeding
- Gardening/small animal raising
- Adequate medical care, e.g. to treat parasitic infections
- Monitoring of child growth and development
- Pre-Natal Care

Discuss ways to combine teaching mothers about preventing both diarrhea and malnutrition.

Step 4 (45 min.)

Teaching Mothers About Feeding During and After Diarrhea

Ask the group to count off to form three groups. Distribute one of the case studies from Trainer Attachment 9B to each group and ask them to develop a plan (using the planning worksheet from Session 19) for a health education session that could prevent this situation in the future. Trainer Note

During this step tell the group that Chapter 25 of Helping Health Workers Learn provides useful ideas and methods for teaching nutrition. Also recommend Bridging the Gap.

Step 5 (45 min)

Reviewing Their Plans

Ask one member from each group to read their case study to the group, then present and explain the nutrition education plans they have developed for helping the community solve and or prevent this problem from reoccurring.

After each small group has finished their presentation ask the large group for their comments. Have the group focus on:

- The constraints they see in implementing this activity.
- The cultural appropriateness of the activity.
- The approach used (e.g., lecture, dialogue, discussion, participatory/experiential).
- The respect that the activity shows for people's knowledge and beliefs and practices.
- The extent to which community members will be involved in carrying out the activity.

Close the session by making plans to carry out one or more of these session plans during or after the Training course.

Optional Step 6 (60 min)

Nutritional Rehabilitation

Ask several participants to describe what is meant by Nutritional rehabilitation". Have participants discuss the idea of nutritional rehabilitation done in the home, or with mothers, groups and other modifications of the idea. Discuss feeding of a sick child and extra "catch-up" mea-is as part of nutritional rehabilitation. Have several participants discuss how proper use of weaning foods may be seen as nutritional rehabilitation.

Ask another participant to discuss the concept of Nutritional rehabilitation. Centers (NRCs) using Trainer Attachment 9C (Nutritional Rehabilitation Centers). Hold a discussion on the purposes, activities and need for an NRC in your area. If possible, arrange for a visit to a local rehabilitation. Center to observe and learn.

Specifically discuss the role of nutrition education and appropriate food preparation which NRCs serve and why this function is so important.

Ask participants to explain how most mothers learn about child development and good child nutrition in their host country and why some mothers might be at risk for not learning that kind of information. (Participants should dray on information from Session 13 (The Impact of Culture on Diarrhea) for this latter discussion as well as their own community experience).

Trainer Note

Use this step for health volunteers working in nutrition and Diarrheal disease control. You can also use it as a minisession for a few people with this interest.

The main purpose of nutritional rehabilitation. Is to educate the mother through her active participation in the care and rehabilitation. of her child. See Trainer Attachment 9C (Nutrition Rehabilitation Centers) for more background.

Discussion should include the role of NRCs as "parent education" centers and why this may be needed in the country. Such things as the new mobility of the family or change in the family structure, lack of formal parenting education (either in the form of general education, or the health system) to help replace the eroding traditional informal system of teaching child care/nutrition may be reasons why such places are important. The role of the "housemother" in most NRCs may also be discussed.

The main points they should observe and learn in the Nutritional rehabilitation. Center are:

- How are they organized (buildings, staff, equipment, supervision, record keeping).

- Types of cases they treat (severe and uncomplicated PEM cases)

- Types of subjects or topics they teach (nutrition, meal planning, health household budgeting, gardening, home craft skills)

- The work schedule

- Follow-up practices in the home or community

If a visit to the Nutritional rehabilitation or Mothercraft Center is not possible, invite the supervisor of this type of center to discuss his or her program with the group. Whichever way you choose to conduct this step, please review Joan Koppet's book Nutrition Rehabilitation for good information on planning and operating a Nutritional rehabilitation. Center.

Optional Step 7 (60 min.)

Preparing Multimixes

Briefly review the concept of "multimixes". Demonstrate the preparation of multimixes using local foods. Distribute Handout 9A multimixes as Village Level Weaning Foods). Divide in three or more groups (depending on number of participants and stations set up) and have each group go to the stations for preparing multimix weaning focus as described in Trainer Attachment 9A Guide for Multimix Preparation Stations). Give the group 30 minutes to prepare and measure out appropriate portions of the mix. Have them refer to Handout 9A as they do this, and Jot down notes regarding information they would share with parents on Super porridges".

After participants finish preparing the multimix, discuss:

- cultural acceptability of multimix
- how they could use multimix in their teaching about nutrition after diarrhea,

Trainer Note

If participants have not learned to prepare multimixes in their previous training, and plan to do nutrition education along with ORT, use this step as a part of one session or as an extra mini session for those interested. Refer to The Technical Health Training Manual, Sessions 28 (Foods and Nutrition) and 30 (Breastfeeding and Weaning) for basic background on nutrition and child feeding requirements.

Multimixes (super porridges) are nutritionally sound, easy to prepare weaning foods made from ingredients that are already widely available and acceptable to the community. To the extent that this is not true of the prescribed recipes presented in Handout 9A, (Multimixes as Village Level Weaning Foods) modify the ingredients of the multimix for your area.

In the discussion be sure to note the possibility that in some cultures or groups in which separate items of family food contain the important different food elements (such as fish or oil, greens and rice) it may be irrelevant or distasteful to ask the mother to mix all these together.

You may want to invite local children to eat the multimix as prepared by participants in a nutrition education activity such as the one planned in Step 4.

Handout 9A: Multimixes as village level weaning foods

Components

1. The staple

The main source of calories in a village-level weaning food will be the local staple. If alternative staples are available in the particular community, the most nutritious should be used, with special regard to its protein content. In particular, if culturally acceptable, a cereal should be employed in preference to a tuber or plantain (Table 1).

It is often insufficiently appreciated that if the staple is a tuber or plantain, it will itself be bulky. high in water and fibre, and a poor source even of calories, especially with · child's small capacity.

It may, therefore, be necessary to consider the feasibility of adding'. compact calories " to dishes. In West Africa, this has been carried out with red palm oil, and in East Africa, with other vegetable oils and with sugar. Another source of ready-to-eat, easily mashable " compact calories " is the avocado pear.

2. Legumes

Protein will almost certainly have to be derived mainly from legumes. Selection will depend not only on protein content, but also on local availability and cost, cooking properties and apparent digestibility, and cultural attitudes as to suitability for young children.

Because of their undoubted poor digestibility, it is important to see that legumes are well cooked and carefully prepared. For example, the skins should be removed from dried red beans (Phaseolus vulgaris) before cooking by soaking or scalding, or after cooking by sieving. Particular care is needed with the soya bean.

· Reprinted, with slight modifications, from Jelliffe (1967 C).

3. Animal proteins

In almost all places, animal protein is in very short supply, 60 that it is important to use it advantageously.

Firstly, attempts should be made to incorporate portions of all available animal proteins into the weaning food, These may include such widely used protein foods a. eggs, fish meat and cow's milk, but other more unfamiliar sources should be considered, such as acid milk preparations, village cheeses duck's eggs, fermented shrimp paste, edible insects, etc.

Secondly, if practicable, the available animal protein should be given throughout the day and eaten in small amounts intermixed with as many meals as possible.

4 Dark green leafy vegetables

These are often much too little wed by tropical communities, especially for infant feeding. They represent an excellent source of carotene, vitamin C, iron, and the vitamin, B complex, as well a, protein, whose amino acid composition complement that of staple foods

Principle of Multimixes

Most communities have by age-long experiment come to use foods in mixtures, so that their nutrients complement one another in fact, an important generalization in relation to human diets is that the wider the range of foods included and the greater the variety, the less the likelihood of nutritional deficiency

The best way of planning · nutritious, village-level weaning food is as a mixture of ingredients, designed to complement and mutually reinforce one another, in particular to ensure a simultaneous intake of the full range of essential amino acid' at the particular meal (see also p. 188)

With this principle in mind, three types of mixture can be considered All are built around the staple, with the addition of one, two or three other foods These are known a' double mixes, triple mixes and quadrimixes, respectively (Table 2)

1. Double mixes

These consist of the local staple (preferably a cereal grain, it more than one staple is used by the community), together with the most suitable legume, or animal protein, or dark green leafy vegetable.

Initially, a double mix containing 4 parts of staple to I part of legume can be used, with a gradual increase in the legume content until a 2:1 mixture is used.

In this mix, the essential amino acid lysine, deficient in the staple, is supplied by the legume, which is itself lacking in methionine, available from the staple (Table 1).

Traditional double mixes sometimes used for infant feeding in different parts of the world, include sweet potatoes with red beans (Rwanda) and rice with soya bean (Indonesia).

Alternatively, the staple can be directly reinforced with an animal protein, with its abundant surplus of essential amino acids. Examples include various cereal porridges with added egg or milk. Less satisfactorily, the staple can be mixed with dark green leafy vegetables.

3. Triple mixes

Sometimes it may be possible, if only for an occasional preparation to reinforce a " double mix" of staple and legume with small amount" of animal protein, thereby converting it into a " triple mix ".

This approach ensures that the child will be receiving calories, while the surplus essential amino acids from the animal protein will be available to complement and reinforce still further the essential amino acids of the vegetable protein mixture.

Typical examples of triple mixes used for infant feeding include plantain, pounded groundouts and egg in Buganda, East Africa, and a mixture made of soft boiled rice, Bengal gram (chickpea) and milk in India.

Alternatively, triple mixes may be prepared from a mixture of staple, dark green leafy vegetables and a small quantity of animal protein; or from staple, legume and dark green leafy vegetable.

3. Quadrimixes

It local food resources and local practices permit, the staple, legume and animal protein " triple mix" can be converted into a " quadrimix " by adding small quantities of dark green leafy vegetables, which are sources of vitamin A (beta-carotene) and vitamin C, as well as of protein and iron.

The nutritional value of the various weaning food mixes suggested increases the number of ingredients (Table 2). In planning mixtures, therefore, the aim should be to use the largest number of these ingredients, especially quadrimixes containing small quantities of animal protein, but double or triple mixes containing no animal protein may also be used, if need be.

Trainer Attachment 9A: Ali's story

All was a large healthy baby when born. His mother breastfed him whenever he gave his "hungry cry". By six months All had kits first tooth and seemed to be growing faster than his cousin, who was born 3 weeks before All. His mother was happy. Two of her four children had died during infancy, but tints time All looked quite healthy and happy. She was proud and content and continued to breastfeed Ali. On occasion she would give him a millet gruel. He seemed to like it, but she didn't have tine to make him a separate meal each day. She had a heavy schedule already; fetching water and wood, pounding millet, working in the fields, making single pot meals over the fire, going to the market, caring for her children, sweeping sand and chasing animals out of the house.

During the second half of All's first year, he didn't seem to grow and develop as fast. He had frequent bouts of diarrhea. He was given some of the left-over rice at times when Just breastfeeding didn't seem to satisfy him. All's mother did not know that he was now behind normal growth and development. When All was 9 months, his mother abruptly stopped breastfeeding him. She learned that she was pregnant again, and believed that a pregnant woman's milk was not good. So All was expected to eat from the communal bowl with the rest of the family. The food was spicy and Ali was not accustomed to anything but the rice. His mother watched sadly as ha became thin and miserable. He was frequently 111 with diarrhea and seemed to stop growing. This is what had happened to her other two children. She was sure he was going to die, but accepted it as her punishment for being too proud and content with All when he was an infant.

Trainer Attachment 9B: Case studies

Case Study #1

Food had never been abundant in the village of Afar, as it was in the desert and the main roads leading to the town were often covered with sand. Host of Taraba's large family were undernourished and frequently had runny tummy's. Her youngest child, Sari, was born small and seemed to be a slow learner. Taraba, being undernourished herself, had very little breastmilk to give her young child. Sari received goats milk and occasionally water mixed with a little dried milk and some porridge. Whenever Sari received the powdered milk mixture, she had a runny tummy and refused to eat. The local healer was away and Taraba had no money to take Sari to a clinic. Her husband's peanut crop had failed again because there was no rain and what he had stored to sell and feed the family was damaged by insects and rats. Her husband went into debt. What little food was available, kept the family alive and he had no surplus to pay for Sari to go the clinic.

Case Study #2

Kiku was a healthy baby. At 18 months she was still befog breastfed and receiving some supplementary food on occasion. At times, Kiku's mother (Aru) attended a clinic where Kiku was weighed and Aru given a soybean meal to prepare at home for Kiku. When Kiku. became sick with a cold and diarrhea, Aru immediately stopped feeding her, believing that food made the diarrhea worse. At first Aru did not take Kiku. to the clinic because it did not seem necessary, she would get better. But then Kiku. became worse. She developed a heavy cough and fever and was very weak from the illness and lack of food. By now Aru was too ashamed of her condition to take her to the clinic. She decided to go to a traditional healer instead.

Case Study #3

Jose was 2 1/2 years old when he returned from the hospital 40 miles away. He had suffered from a severe case of protein deficiency and stayed at the hospital for two months getting treatment. He was now at a weight appropriate to his age and in fairly good health, so he was allowed to go home. His family was happy to have him back home. His younger sister was now 10 months old and beginning to eat some of the family food too.

Jose quickly went back to the familiar pattern - of eating yens one day, rice the next. He was also back to the familiar environment with the pigs and goats wandering around the yard. It became his Job to chase them away from the cooking area. Jose soon had worms again, like all the other children. His belly was bloated and hard, he was either constipated or had diarrhea and frequently his mother saw worms in his poop. She didn't know where they came from or what damage they did to her son. After a few months, Jose began to show the signs of Kwashiorkor again, puffy looking ankles and hands, thin upper arms and he was always miserable and not hungry. His parents didn't know what to do - they couldn't afford to send him back to the hospital. Besides it didn't seem to cure him since the "disease" came back so fast.

Trainer Attachment 9C: Nutritional rehabilitation centers

H. DE LAUTURE, I. WONE, M. PERIER-SCHEER and C. PENOT

Introduction

More than 20% of Senegal's rural children aged 1 to 4 suffer from protein-calorie malnutrition (PCM). PCM in children results from poor, unbalanced or insufficient diets.

To correct these diets, nutritional rehabilitation centers (NRCs) have been established in the villages of Babak and Pambal, in the region of This. Children and mothers come to these centers for periods of up to three weeks. Mothers learn to use locally available food products, and to prepare well-balanced meals high in calories and proteins needed by children. In this manner, mothers can provide their children with 890-1,420 calories and 41-62 grams of protein daily.

Results of the teaching process are determined by observation of weight-curve records and of clinical symptoms in a child. In 72% of the cases on file, substantial weight gains have been noted, and in 75%, clinical symptoms have disappeared.

The centers have socioeconomic appeal as well, since a three-week NRC stay costs only 5,250 CFA (Communauté Financière Africaine, carrying a current exchange rate of 300 CFA/$1), or about $18. This cost compares to 45,000 CFA - about $150 - for a 15-day hospital treatment period. Hospital treatment also lacks the educational aspect of the NRC method, which emphasizes self-sufficiency in food and encourages personal initiative.

This map shows the locations of the villages of Babak and Pambal where the nutritional rehabilitation centers have been established as part of existing health centers in the rural sectors of the province of This. Each village contains about 1,000 residents. The Babak center, a privately run Catholic station, operates three outlying posts, each supervised by a nun who is assisted by a midwife, assistant nurses and an office worker. The state health station at Pambal also operates a nearby medical outpost. Advanced cases of malnutrition which cannot be handled in the rural centers are treated in urban hospitals, such as in the Senegalese capital of Dakar.

Few Senegalese mothers are skilled in handling the dietary transition from nursing to adult food for their children who generally shift from the nursing stage to a regular diet between the ages of 18 and 30 months. While many mothers do provide supplementary nutrients - such as a millet semolina mash - to their children during the later nursing period, the practice rarely continues once nursing ends. The abrupt transition to an adult diet, which often lacks sufficient protein and calories for a child's needs, can result in protein-calorie malnutrition (PCM). At least 20% of Senegal's children aged i to 4 are affected by two broad types of PCM: marasmus, more common in rural areas, and kwashiorkor, usually found in urban areas. Complicating factors include the likelihood of infections and parasitosis, along with anemia and multiple deficiencies of minerals and vitamins A and B. Because these factors rarely occur independently, it is often difficult to determine which type of malnutrition is responsible for a child's condition. But the use of Simple indicators to detect malnutrition in its early stages can help prevent the degeneration of the disease and expedite its treatment in rural settings.

Rural treatment more effective

Malnutrition, a leading cause of illness and death among Senegal's children, has traditionally been treated in urban hospital settings. But a more inexpensive and often more effective treatment for many cases of malnutrition is emerging in rural health centers, such as the one at Babak, where Catholic nuns work with malnourished children and their mothers to treat the disease and to prevent its recurrence. These nutritional rehabilitation centers (NRCs) emphasize the importance of the mother's role in creating and maintaining a balanced diet for the child once treatment ends. An average NRC stay for mother and child costs about 1/10 that of a hospital stay, and appears to be more effective in preventing malnutrition once the mother and child return home. Because the NRCs in Babak and Pambal reflect the traditional' rural setting, they car serve as demonstration models for other centers in similar areas.

Preventing the recurrence of PCM in a child once treatment ends involves careful training of mothers in the use of locally available foods which contain sufficient calories and proteins for a child's nutritional needs. This aspect is particularly important since the Senegalese tend to reject "free" food offered by officials once treatment is over, preferring to use foodstuffs purchased or cultivated at home. While many high-nutrition foods are not generally consumed by children living in rural Senegal, items such as dried fish, cherry tomatoes, onions and peanut flour can be incorporated into a family diet at little additional cost. NRC workers stress the necessity of maintaining a balanced diet for children, using the traditional cooking techniques of the typical rural home during the mothers' stay at the center to reinforce continuation of that diet after treatment ends. Mothers are also taught better methods of selecting, cultivating and preserving foods in the home environment, along with specific recipes for use during the weaning period and other stages.

Depression a sign of malnutrition

The sad eyes of depression are often a sure sign of the onset of PCM in a young child, along with such physical symptoms as brittle hair, skin lesions, abnormally low weight, edema and digestive disorders. Malnourished children are generally sad and irritable, often refusing to play or respond to their surroundings. Smiles are rare among malnourished children. But successful treatment of the disease can restore the bright smile of infancy to a child's face, a small but important step toward the larger goal of preserving the vitality of the developing population in Senegal Because the NRC approach seems more effective, at least in studies thus far, in preventing a recurrence of PCM, it may become a widespread alternative to traditional hospitalization. Limited resources are available at present, but the success of the Babak and Pambal centers serves as a beacon in the treatment of PCM. Elimination of malnutrition as part of a larger economic development policy depends on community awareness, the NRC approach, aimed at establishing a permanent dialogue on both therapeutic and educational levels, is an efficient model for others to follow.

Examples of Recipes used in Nutritional rehabilitation Centers:

Chart 1: The "Gar" recipe

Nutrients in grams	Quantity in grams	Calories	Proteins
Millet semolina	600	1,920	40
Dried fish	285	598	120
Sorrel leaves (bissap)	300	141	11
Cherry tomatoes	1,200	252	12
Onions	300	93	2

Note: This preparation contains 3,004 calories and 185 grams of protein, and provides 150 tablespoons of food. Its sharp taste reflects its high content of minerals (calcium, phosphorous and iron) and vitamins.

Chart 2: The "Lakh-Thiakhane" recipe

Nutrients in grams	Quantity in grams	Calories	Protein
Millet semolina	900	2,880	60
Dried fish	300	927	127
Cherry tomatoes	150	31	1
Peanut semolina	300	1,740	77
Bissap sorrel (fresh calyx)	75	33	3
Niebes beans	225	779	52
Onions	75	23	0.5

**can be replaced by fresh fish or meat

Note: This preparation is Wolof, well known throughout Senegal. Easily and quickly digested, it is especially nutritious for a weaned child. It contains 6 413 calories and 321 grams of protein, and provides 147 tablespoons of food.

Chart 3: The "Natt" recipe

Nutrients in grams	Quantity m grams	Glories	Protein
Niebes beans	1,000	3,460	233
Cherry tomatoes	1, 150	241	12
Dried fish	150	315	63
Onions	275	85	2
Sorrel leaves (bissap)	137	64	5
Peanut flour	250	1,450	65

Note: This preparation is well-adapted to use during weaning because of its high content of protein, calcium and iron. It contains 5,615 calories and 380 grams of protein. It will prepare 51 tablespoons of food.

Chart 4. Diets using these recipes

Lunch	Dinner	Calories	Protids	% Proteidic Calories
Natt	Gar	650	41	25
Gar	Natt	650	41	25
Natt	Lakh	770	45	23
Lakh	Natt	770	45	23
Natt	Gar	650	41	25
Gar	Natt	650	41	25
Natt	Lakh	770	45	23

Note: The nutritional needs of the child are best met by providing two main meals during the day - one at lunch, one at dinner - and two snacks, one in the morning and one in the afternoon. Maternal nursing should continue as a nutrient until weaning is completed, with a minimum of 500 grams of milk per day 1325 calories and 7.5 grams of protein. A least five tablespoons of each preparation in the diet are considered a minimum per meal.

Trainer Attachment 9D: Guide for multimix preparation stations

For session 9 the trainer should set up 2 or 3 work stations where participants can prepare the locally used recipe for multimix weaning foods.

Provide the raw ingredients for the mix which will likely include the following kinds of ingredients (after Handout 9A):

- a legume of some sort (e.g.: beans, peanuts, dahl, lentils, etc.)

- the local staple (e.g.: cassava, rice, corn, maize, etc.) - a green leafy vegetable (greens, of some sort)

- a piece of dried fish, cooking oil or egg, etc.

Be sure the necessary utensils are provided for the proper preparation of these mixes. These may include a mortar and pestle, knives, spoons, mashers, strains/sieves, bowls, kettles, etc. Also be sure that a water source is available for washing raw ingredients if beginning "from scratch" and that other kitchen-like amenities are available.

Depending on the availability of a heat source for cooking these foods, or equipment to pound the fish, rice, etc. for use in the mixtures, participants may only be able to do part of the multimix preparation - either the beginning or the end. If this is the case, have either the finished product or raw ingredients there for them to see, taste, etc. explain any of the steps in the preparation of the multimix which they were unable to participate in and have them share their own experiences with preparation of these foods or similar foods to compensate for the lack of firsthand experience in this step.