Hoer\ue9e, Tom F.

Kolsteren, Patrick W.

Sejas, Edgar V.

Ventura, Adolfo F.

Bioline International

J HEALTH POPUL NUTR    2005 Jun;23(2):200-201 © 2005 ICDDR,B: Centre for Health and Population ResearchISSN 1606-0997        $ 5.00+0.20LETTER-TO-THE-EDITORThe Role of Curative First-line Health Services inEnhancing Screening and Rehabilitation of Mild-to-Moderate Malnutrition: Results of a Pilot Project in BoliviaSir,Mild-to-moderate malnutrition constitutes an importantpart of the burden of disease for young children in deve-loping countries (1). In association, and even synergy,with infectious diseases, estimates of the contributingrisk on the burden of disease and mortality of all formsof underweight vary between 49% for diarrhoeal dis-eases and 45% for lower respiratory infections or malaria(2). Due to its higher prevalence, its early detection andeffective treatment (secondary prevention) has the po-tential of significantly contributing to child survival. Upto the early nineties, growth monitoring followed bynutrition education__also called growth monitoring andpromotion__was considered the most effective strategyfor primary and secondary prevention of malnutrition.Still, evaluations under routine conditions (3), trials es-timating effectiveness (4), and reviews on performance(5) could not confirm this hypothesis.Scepticism grew and at the Nyeri conference in 1992,the recommendation was released to work on innova-tive alternatives to the growth-monitoring and promo-tion approach (6). Backed up with this evidence andbased on our own frustrations with the ineffectivenessof the growth-monitoring programme at our health centrein rural Bolivia, we conceived and evaluated an alter-native to the growth-monitoring and promotion prog-ramme. We estimated the added value of screening all chil-dren attending curative services compared with screen-ing during preventive activities for malnutrition (wast-ing, weight-for-height ≤-2 z-scores of the National Cen-ter for Health Statistics reference; over a 23-month periodfrom February 1996 to December 1997). The rationalebehind this screening strategy is that the positive pre-dictive value will increase because of the increased pre-valence of malnutrition among children with infections.In the health area, curative consultations are held everymorning, except on Sundays, and growth monitoring isorganized on a monthly basis at community level. Of1,969 children screened during curative consultations,87 malnourished cases were detected. Of 1,921 childrenscreened during preventive contacts, 20 malnourishedcases were detected. So, detection rates were 4.42% and1.04% respectively, putting the relative risk of detect-ing a malnourished child during curative consultationsat 4.24 (confidence interval 2.62-6.87, p<0.001). For the mild-to-moderate malnutrition cases, a home-based rehabilitation programme with ambulatory weeklyfollow-up at the health centre was offered. The rationaleis that educational messages need to be simple, con-text-specific, and repeated to be effective. The optimalduration of this educational strategy was measured. Theimportance of giving at least five meals or snacks perday was stressed, and parents were advised to add twospoons of cooking oil to each cooked meal to increasecaloric density. Weight controls were extended to 12weeks, and defaulters were visited at home and moti-vated to attend. Twenty-seven children with mild-to-moderate malnutrition, resident in the health area, wereenrolled in this programme (median age: 15.1 months;male: female ratio: 1.25). Two children absconded with-in two weeks and could not be traced. All other chil-dren (92.6%) came regularly for the whole 12-weekperiod. Calculating the weight-for-height z-scores perchild at 0, 4, 8, 12, and 32 week(s) after the initiation ofthe programme showed that all the children recoveredwithin the first month of follow-up (Table). At the startof the programme, their median weight-for-height z-score was -2.2 increasing to -1.3 four weeks later. ScoresCorrespondence and reprint requests should be addressed to:Dr. Tom F. HoeréeDepartment of Public HealthPrince Leopold Institute of Tropical MedicineNationale str. 155, 2000 AntwerpBelgiumEmail: thoeree@itg.beModerate malnutrition and first-line health services 201REFERENCES1. Black RE, Morris SS, Bryce J. Where and why are10 million children dying every year? Lancet 2003;361:2226-34.2. Ezzati M, Hoorn SV, Rodgers A, Lopez AD,Mathers CD, Murray CJ. Estimates of global andregional potential health gains from reducing mul-tiple major risk factors. Lancet 2003;362:271-80.3. Gerein N, Ross DA. Is growth monitoring worth-while? An evaluation of its use in three child healthprogrammes in Zaire. Soc Sci Med 1991;32:667-75.4. George SM, Latham MC, Abel R, Ethirajan N,Frongillo EA, Jr. Evaluation of effectiveness of goodgrowth monitoring in south Indian villages. Lancet1993;342:348-52.5. Dixon RA. Monitoring the growth of the world'schildren. Ann Trop Paediatr 1991;11:3-9.6. Anonymous. Growth promotion, not growth moni-toring. Lancet 1992;339:1409.Tom F. Hoerée1, Patrick W. Kolsteren1,Edgar V. Sejas2, and Adolfo F. Ventura21Department of Public Health, Prince LeopoldInstitute of Tropical Medicine, Nationale str.155, 2000 Antwerp, Belgium and 2Unit of Nutrition, Faculty of Medicine, SanSimon University, Cochabamba, Boliviaimproved further to -1.1 at 8 weeks and -0.6 at 12 weeks.Seventeen children who could be traced at around 32weeks had a median z-score of 0.3. Table. Weight-for-height z-scores at the start, 4, 8,12, and 32 weeks of the rehabilitation prog-ramme (median and 95% confidence interval)Observation               No. Median         CI 95%periodDiagnosis 25 -2.2 -3.0,-1.94 weeks 25 -1.3 -2.1,-0.88 weeks 25 -1.1 -1.7,0.212 weeks 25 -0.6 -1.2,-0.132 weeks 17 0.3 -1.0,1.2CI=Confidence intervalIn this pilot experience, screening for malnutrition dur-ing curative consultations yielded clearly more casesthan during routine growth monitoring. This result is anindication that the theoretical basis of our screening stra-tegy__malnutrition, especially mild-to-moderate malnu-trition, as an overlooked co-morbidity__may hold true forour pilot population. It, thus, strengthens the idea of in-troducing systematic screening at first-line curative ser-vices. The results of our rehabilitation programme indi-cate that follow-up of mild-to-moderate malnutrition doesnot need to be long. A four-week programme could besufficient to educate parents. However, our design doesnot allow us to assess the added benefit of our prog-ramme to the one-time nutritional advice in growth moni-toring and promotion, nor do we know the cost of or howthe parents appreciated the programme. These questionswill be addressed in a research project we are currentlydeveloping. 

The Role of Curative First-line Health Services in Enhancing Screening
and Rehabilitation of Mild-to-Moderate Malnutrition: Results of a Pilot
Project in Bolivia

The Role of Curative First-line Health Services in Enhancing Screening and Rehabilitation of Mild-to-Moderate Malnutrition: Results of a Pilot Project in Bolivia

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