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, DOCUMENT RESUME ED 371 865 PS 022 466 AUTHOR Pelletier, Jean-Gerard TITLE Severe Malnutrition: A Global Approach. INSTITUTION International Children's Centre, Paris (France). REPORT NO ISSN-0379-2269 PUB DATE 93 NOTE 88p. AVAILABLE FROM Children in the Tropics, International Children's Centre, Chateau de Longchamp, Bois de Boulogne, 75016, Paris, France ($10; annual subscription: $40 for 6 issues). PUB TYPE Collected Works Serials (022) JOURNAL CIT Children in the Tropics; n208-209 1993 EDRS PRICE MF01/PC04 Plus Postage. DESCRIPTORS Biological Influences; *Child Health; Children; Cultural Influences; Developing Nations; Disease - Incidence; *Diseases; Foreign Countries; Global Approach; *Hunger; *Intervention; Medical Services; *Nutrition; Nutrition Instruction; Poverty; Program Evaluation; Rehabilitation; Socioeconomic Influences IDENTIFIERS Anthropometry; KwashisKor; Marasmus; Psychological Influences ABSTRACT This report examines the immediate and underlying causes of malnutrition in the developing world. The first section discusses the effects of malnutrition on childhood development and examines the efficacy of nutritional rehabilitation. The second section addresses the medical effects of severe malnutrition, including the onset of ponderostatural (weight) retardation, behavioral disorders, dehydration, anemia, hypothermia, hypoglycemia. and diarrhea. The third section focuses on anthropometric approaches to treating malnourished children, which treat children on an individual basis based upon their particular condition. The fourth section examines the biological effects of severe malnutrition, discussing deficiencies in serum proteins, electrolytes, trace elements, and hormonal levels, along with their immunological consequences. The fifth section explains the nutritional approach to the problem, looking at protein, vitamin, and mineral deficiencies lnd specific rehabilitation procedures and foods. The sixth section focuses on a cultural approach to malnutrition, discussing dietary and social customs that affect nutrition and eating behaviors. The seventh section examines psychological approaches, looking at the mother-child relationship, psychological problems fostered by malnutrition, and specific interventions. The eighth section addresses social and economic approaches to malnutrition, while the ninth section examines techniques used to evaluate rehabilitation and treatment programs. (MDM) *********************************************************************** * * Reproductions supplied by EDRS are the best that can be made * * from the original document. *********************************************************************** IL I I 0 1 U E. DEPARTMENT OF EDUCATTON Educattonat Reeetuch end itsprmemsm OM:* EDUCATIONAL NEW IRCES INFORMATION CENTE.. AMP yllus document has been ussuoducise as Amami from too 1:41101% Of agamiatton angtnahng 11. 0 Minor changes have WNW made to wnofoue reproduCton oughts ewes of yew of asuman* slated m the dock,- rneM dO not noceseenN moment MOcial OERI pomOon or poltey Aft ." " *:"Za : N "PERMISSION TO REPRODUCE TI SEVERE MALNUTRITION : MATERIAL HAS BEEN GRANTED A GLOBAL APPROACH 1993 - N° 208-209 TO THE EDUCATIONAL RESOURC BEST COPY AVAILABLE INFORMATION CENTER (ERIC)" INTERNATIONAL CHILDREN'S CENTRE PARIS 2 16. The International Children's Ce.--' .! was created by the French govern- in particular, follo- ment in 1949, on the initiative of Professor Robert Debré wing negociations between France and he United Nations. Its purpose was to furnish those international and natior 11 agencies dealing specifically with ducational and informational tools in child care with training facilities 3nd their family the field of child health and development, viewing children within and surroudings. devoted its ICC soon turned essentially toward Third World children and activities to the training and education of personnel with social, educational and administrative responsibilities as well as medical and paramedical workers.The desire for greater efficiency has led it to work increasingly with trai- methodological and educational ners and to concentrate its efforts on the aspects of mother and child care programmes. ICC is also engaged in an attempt to further study - and - action on some contribute to aspects of the life and health of children and their family, so as to planned practical improvement, particularly in the fields of growth, nutrition, preschool parenthood, the control of transmissible and nutritional diseases, and school education, the needs of disabled and underprivileged children, etc. The documentation centre of the ICC has been collecting, processing and circulating invaluable information on children and their environment for the developed the Robert past forty years. In the last decade the centre has also Debré Database (BIRD) ; with its current 110,000 references, it can meet your bibliographic research needs either by correspondence or by visiting the upda- centre's library. Furthermore the ICC also produces the BIRD CD-ROM, disc ted yearly with the latest database references; it is a user-friendly compact operated on any IBM compatible PC equiped with a standard CD-ROM drive. docu- ICC also publishes books, proceedings of symposia and educationa! bulletins. ments, as well as comprehensive analyses and bibliographic As for its legal status, the International Children's Centre is a foundation under french law of recognized public utility, administered by an executive board with broad international membership. +- IN THE TROPICS REVIEW OF THE INTERNATIONAL CHILDREN'S CENTRE SEVERE MALNUTRITION : A GLOBAL APPROACH 0 JEAN-GERARD PELLETIER N° 208-209 1993 - On Sunday, 10 October 1993, Professor Djilali BELKHENCHIR was assassinated by several young men, in front of his paediatric department at Birtraria, in Algiers. He had often worked with the ICC on subjects such as the behaviour of adolescents and the evaluation of health programmes, sharing with us his sound competency, broad experience and pro- found philosophy, which he never failed to put Into everyday practice, and which may be summed up in a very few words : "children first". His 1985 doctoral thesis in medicine, on infant diarrhoea, for which he earned the Nathalle Masse award, was prefaced by the following dedication : "I dedicate this thesis to young Omar SAADI, who died in the battle of Algiers at the age of 11, because he believed that justice could be achieved In this country. To all those little fellows out on the streets throughout the world, who die each day, standing side by side with their elders, for the same ideals." We hope that all those who knew and appreciated him are as deeply affected as we are, and will uphold the memory of his example. 5 3 Malnutrition has numerous causes 7 REHABILITATION : Nutntional rehabilitation GLOBAL CARE ? 11 CLINICAL Severe forms of protein energy malnutrition 14 APPROACH 14 Marasmus Kwashiorkor 15 Marasmus-kwashiorkor 17 Difficulties in treatment 17 Dehydration and fluid and electrolyte disorders 17 Anaemia 19 Hypothermia 19 Hypoglycaemia 20 20 Cardiac insufficiency 20 Infections 25 Prognosis Review of the main anthropometric tools 27 ANTHROPOMETRIC 27 Data collection APPROACH Analysis of findings 28 Anthropometrics and nutritional rehabilitation 31 Detection and management of children 31 Assessment of the severity of malnutrition 32 33 Assessment of the child's recovery 35 Biological consequences BIOLOGICAL 37 Hormonal consequences APPROACH Immunological consequences 38 40 Biological assessment and nutritional rehabilitation NUTRITIONAL 42 Needs APPROACH Therapeutic renutrition 46 46 The different stages Breast-feeding 46 .11 The anthropology of diet 51 CULTURAL 54 Social and cultural anthropology APPROACH 56 Medical anthropology The role of the psychological setting in malnutrition PSYCHOLOGICAL 61 62 Tools for wholesome development APPROACH 65 Psychological intervention during rehabilitation 65 Changes in behaviour 68 The intervention itself Psychotherapy 71 72 Evaluation 73 Stimulation and home follow-up 74 Tools for analysis SOCIAL AND 76 Socioeconomic characteristics ECONOMIC A therapeutic attitude 77 APPROACH 78 The purpose of evaluation EVALUATION OF Effectiveness of programmes 81 REHABILITATION PROGRAMMES 7 5 In 1989-'4, Jean-Gerard Pelletier worked in Cochabamba, Bolivia, Jean-Gerard within a team of young i3orrvian practitioners who were trying to PELLETIER put this global approach to severe infantile malnutrition into every- by Dr. R. Sevilla, is day practice. Their rehabilitation centre, located in the paediatric department headed by Dr. Lopez within the German Urquidl Hospital. The author of the present document takes entire responsibility for everything it contains, but wishes to state that his experience within this very dynamic team was most valuable for the formula- tion of this overview. He expresses his thanks to : Dr. R. Sevilla and Dr. E. Sejas, paediatricians, Dr. P. Brun (French non-governmental humanitarian agency, "Aux Ouatre Coins du Monde"), Ms. M.L. Flores and Mr. J.C. Lafuente, students of psychology, Mr. P. Chevalier, nutritionist at the ORSTOM, Ms. L. Zalles, biologist and Ms. E. Suarez, student of sociology, the nurses and nurses' aides. In 1988, a Centre for Complete Nutritional Rehabilitation, the CRIN, was created In Cochabamba, Bolivia, on the initiative of a group of nutritionists from the Institut Francais de Recherche Scientiflque pour le Developpement en Cooperation (ORSTOM) and yormg paediatricians from Bolivia's San Simon University, supported by the French Embassy in Bolivia, "Aux Ouatre Coins du Monde", a nongovernmental agency, and ORSTOM. The objective of the CRIN, which works independently within the paediatrics department of the German Urquidi Hospital, goes beyond the clinical and nutrition-related rehabilitation of seve- rely malnourished children, to include the satisfaction of their basic emotional, cognitive and psychomotor needs, the restimulation of their immunocompetence and an attempt to improve the environment In which these children will again be immersed at the end of their hospital stay. This holistic approach to the treatment of severe malnutrition, based on the action of a pluridisci- plinary team, the CLAPSEN (Clinic, Laboratory, Anthropornetrics, Psychology, Socioeconomics, Education, Nutrition), was the object of an international workshop on complete nutritional rehabilitation (SIRIN), In June 1990, the conclusions and recommendations of which have been published (*). Dr. J.G. Pelletier was a member of this group for close to one year (1989-90). It is this experience, and his reflections on the CRIN and its activities, along with a critical examination of writings on the subject, which have enabled him to write this overview of the global approach to severe malnutrition. 0 SYLVIANE LE BIHAN SECRETARIAL WORK TRANSLATION HELEN ARNOLD "Del nifio desnutrido a la comunidad", conclusions and recommendations of the SIRIN, Cochabarnba, Bolivia, ORSTOM-IBBA-UMSS-MPSSP, La Paz, 1990. 131 8 F61 REHABILITATION : GLOBAL CARE? MALNUTRITION Although the main cause of malnutrition is the qualitatively and quantitatively insufficient intake of food, a closer study of its aetio- HAS logy points to a great many other interdependent factors. NUMEROUS Thes,ik factors, which may be contributory, triggering or precipi- CAUSES tating, have been described repeatedly, and some scientists have even proposed models to evidence their origins, inter-relations and various levels of responsibility (national, regional and also local - that is, village or household levels). If the personnel, commu- nities and families concerned are awae of and understand these mechanisms, perhaps they will be better armed to identify the key factors, and will thus find solutions that are better adapted to both needs and resources, and therefore more productive, in terms of efficiency. These models, which do not confine themselves to nutrition and health-related factors, but take a comprehensive approach, identify the various aetiologies malnutrition. involved in Malnutrition is not simply a childhood disease. Its causes are indicative of precarious living conditions and a more or kw unsatisfactory environment as well. Treating malnourished children means treating the oonse- quences of an ill that is rooted In many sources located above- stream, and in which a number of sectors are involved. Treating malnourished children means working with them within their family and everyday sur- roundings (cf. figure 1) (1). Figure 1 : Different levels of causes of hunger. Source : Jonsson U. -The Causes of Hunger". Food and Nutrition Bulletin. UNU, aprt 1981 ; 3, (2). (1) Jonsson U. 'The causes of hunger". Food and Nutrition Bulletin. UNU, april 1981 ; 3, (2). 7 9 BEST COPY AVAILABLE This figure clearly illustrates the approach required for the study of it supposes a long-term project, and the causes of malnutrition ; one which must be carried out with the participation of families, social and health field workers, but also with many people In char- ge of the other sectors involved (sanitation, food production, the economy, commercialisation, education, law-making, politics, informal associations, etc.). The cultural and religious aspects should not be overlooked, since they play a key role in everyday behaviour, eating habits and attitudes toward health, illness and death. Mothers and Malnutrition is self-perpetuating : a child's nutritional status at any children : the vicious point in time depends on his or her past history, which may partial- circle of malnutrition ly account for his or her present status. To some extent, this nutritional history is linked to the mother's health and nutritional status, which In turn has been influenced by her living conditions and nutritional history during her own childhood (cf. figure 2). Short stature in women may be interpreted as one consequence of poor diet during growth ; they then run the risk of giving birth to children with a low birth weight, a factor possibly contributing to the occurrence of malnutrition. Furthermore, these women often have an insufficient diet during their pregnancy, along with numerous infections. There are other maternal risk factors : a weight for height far below normal at the onset of pre- Nutritional status of woman gnancy, insufficient weight gain of childbearing age during pregnancy (under 6 kg), overly frequent pregnancies (separated by less than 6 months), pregnancy before age Nutritional status 15, multiparity (over five children), at puberty and a past history of delivery of low-birth-weight babies. This approach points to the need Nutritional status of for Interventions to be well tar- lactating woman Girl's nutritional geted : in the long run, action that status confines itself to malnourished children cannot solve the pro- A blem, and this is one reason why we encounter children who re- Neonatal and lapse after hospitalization for Infant nutritional malnutrition, or several siblings status problem. with the same Interventions must take the Nutritional status of child's environment - and espe- pregnant woman cially the mother-child dyad - into account, and should also concentrate on adolescence in Figure 2 : influence of each generation's nutritional status on the fol- girls, a crucial period for future . lowing generation. mothers. I (1 8 t I