Childrens Health Brigade Orientation

Shoulder to ShoulderChildren’s

Health Brigades

The International Child Health Dilemma

• This year nearly 11 million children will die before they reach the age of 5 years.

• 6 million—will die of diseases that could have been easily prevented or treated.

• We are hindered to help by are inability to deliver the appropriate interventions to the populations of need.

“The world’s forgotten children,” editorial” THE LANCET • Vol 361 • January 4, 2003

Major Causes of Child Mortality

• Neonatal Causes• Pneumonia• Diarrhea• Malaria• Measles• Injuries• AIDS• Malnutrition is a

underlying cause in up to half of all deaths.

Child Mortality

• Age, income and location affect mortality

Honduras

• Unemployment rate 28%

• Literacy rate 80%• Average life expectancy: 69 years (average in Latin America is 71)• Population living with under $1 a day (%) 23.8• Population living with under $2 a day (%) 44.4• Undernourished people (% or population) 21• Children under 5, underweight for their age (%) 25

• Children under 5, underheight for their age (%) 39

• Probability of not surviving to age 40 (% of cohort) 13.8

• Pop. w/o sustainable access to an improved water source (%) 12• Source: United Nations SIAP

Child Health Initiative• An evidence based initiative to

improve health of the children in the communities of Intubuca, Honduras where Shoulder to Shoulder has a presence.

• The focus of the CHI is to eliminate preventable death, and to enable each child to reach their social, educational, and economic developmental potential.

• An organized, systemic approach to medical volunteerism designed to demonstrate the ability of regular “brigades” to decrease childhood morbidity and mortality.

Nutrition:Food in School

Children Under FiveBreast Feeding Support

Disease Burden:Parasite Treatment

Anemia SurveillanceVitamin A and Zinc Supplementation

Vaccines

Dental Health:Dental VarnishDental Clinics

Cultural Influence:Library

Artist in Residence

Education:Yo Puedo Scholarship ProgramYo Puedo Leadership Program

Boy Leadership programParenting ClassesSchool Uniforms

Environment:Latrine Project

Potter’s for PeaceBed Netting

Indoor Ventilation

Shoulder to ShoulderChild Health Initiative

Child Health Engagement Projects

Child Health Engagement Projects

• 4000 Children in 100 communities• Visit each primary site twice per year• Deliver Evidence Based Interventions to

decrease mortality and morbidity• Address acute illness noted in community• Obtain data on nutrition, education, anemia,

and ventilation• Introduce Communities to Long term STS

initiatives.

Disease Burden

Intervention Disease Effected

Total Cost

Cost /child

Notes

Vitamin A deficiency

Supply 100,000 IU of Vitamin A to every child every 6 months

Diarrhea PneumoniaMeaslesBlindness

$120 $0.04 50% Reduction of mortality due to Measles

Zinc Deficiency

Zinc Supplementation to every child through fortified daily vitamins

DiarrheaDehydrationStuntingMalariaAnemia

$3000 $1.00 Reduction of Diarrhea course by 2 weeks

Iron Deficiency

Iron Supplementation to all children with hematocrit < 30

AnemiaMental RetardationFatigue

$450 $0.15 Prevents permanent neurological damage in children under 2 and improves cognitive function at all ages

Parasite Infestation

Anti-Parasitic Medication(Albendazole)Single dose every 6 months

Helminthes infestation,Anemia,Malnutrition

$2500 $0.83 Decreases disease burden in total community

Dental Caries

Dental Varnish application (Duraphat) every 4-6 months

Dental CariesDisfiguration

$3000 $1.00 Prevents permanent loss of teeth

MyopiaScreen and provide glasses

Delayed and diminished learning

$350 $0.12 Myopia has low prevalence but disability is substabtial where it exists

Totals $9,920 $3.31

Station 1: Registration

• Accuracy is extremely important• Part of the goal of the initiative is data

collection, following children’s outcomes over time in response to the interventions.

• Remember that most Hondurans have 4 names: 2 first names and 2 last names.

• Registration station should include a local community member as well as a brigade member to ensure quality data

Station 1: Registration

• Include municipality and aldea

• Record date of birth as needed

• Remind children to eat before the dental station, as they cannot eat for 2-4 hours after the station.

Station 2: Dental Care

Good dental health decreases :• Diseases burden• Disfiguration• Topical fluoride is the main stay for prevention of

dental caries. [i] • Dental Varnish application every six months

decreases caries and heals current caries. .[ii]

• [i] Jacobsen P, Young D. “The use of topical fluoride to prevent or reverse dental caries.” Special Care Dentist. 2003 Sep-Oct;23(5):177-9.

• [ii] Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003:CD002782.

Station 2: Dental Station

• Education:• Teaching book available• Best done with parents present.• Usually done in groups of 6 or less children.• Dental Decay is preventable• It is caused by bacteria that multiply with the

presence of sugar.• Limiting foods high in sugar (soda, candy) is

necessary for healthy, pain free teeth.• Parents should brush the teeth of children under 6.

Station 2: Dental Station

• Apply varnish to all children under age 17 who have teeth.

• Give the child a toothbrush if they haven’t received one in the last 6 months and keep it in the wrapper until they get home.

• Record on the record sheet provided what was done (brush, varnish, education).

Station 2: Dental Station

• Operator should wear gloves and change in between patients.

• Child may sit, stand or lay down with head on lap of operator

• Using 2x2 gauze, wipe the outer, inner and chewing surfaces of the teeth.

• Using the applicator brush, apply varnish to the outer and chewing surfaces of the teeth, and if possible, inside surfaces.

• Instruct child to not brush teeth until the following morning and may not eat for 2-4 hours after application.

Iron Deficiency

Leading cause of anemia in children.

• Lower participation in school• Decreased productivity• Mental illness• Mental and motor development delay [i] • Permanent neurological damage [ii]• Death• [i] Hurtado, Elyse Krieger, Angelika Hartl Claussen, and Keith G Scott “Early childhood anemia and mild or

moderate mental retardation”Am J Clin Nutr 1999;69:115–9.• [ii] Scrimshaw NW. Functional consequences of iron-deficiency. J NutritionalScience Vitaminology 1984;30:47–

63.

Station 3: Anemia screening

• Screen all children

• Explain to parent and child what you are doing.

• May use heels for babies

• Fill capillary tube ½ - ¾

• Spin in centrifuge and read with hematocrit reader.

• Record on data sheet and child’s marker card.

Station 4: Anemia Screening

• Treat if Hct <30

• Treat at 3-6 mg elemental iron/kg/day divided QD/BID/TID x one month

• When in doubt, dose with less rather than more

• Instruct parents to keep out of reach of children

• ONLY give if parent present

Station 4: Height and Weight

• Purpose is to calculate z scores for height for age and weight for age and mid upper arm circumference

• Height: • Age < 24 months Use the measuring board. Have the

child lie down on the board with his or her head flush against the top of the board. Extend their leg and read at their heel.

• Age > 24 months Have the child stand against the wall with a measuring tape, with shoes off and use a ruler.

• Record in inches.

Station 4: Height and Weight

• Record in pounds

• Age < 2 Use the infant (hanging) scale. Do not weight the mother, then then mother and baby and then subtract-it is not accurate.

• Age > 2 Weigh without shoes

Station 4: Height and Weight

• MUAC (Mid Upper Arm Circumference) is a quick way to evaluate a child’s nutritional status.

• Check all children 12 months-60 months• MUAC changes little between 1-5 • Measure in centimeters.• Measure the point roughly halfway between

the olecranon and the top of the shoulder

Station 5: Eye Exam

• This is the only opportunity for visual screening for these children.

• Thus far, many have been identified as having decreased visual acuity and have received glasses.

• Use the tumbling E chart

• Show the child the chart up close and practice before the exam

Station 5: Eye Exam

• Test each eye individually

• If either eye is less than 20/50, than measure vision in both eyes together.

• Children with less than 20/50 in either eye will be referred to the Lion’s Club (Club de Leones) Clinic in La Esperanza for glasses. Usually a bus will be scheduled.

Station 6: Health Education

• This is a great opportunity to provide health education for children and parents.

• It is also an opportunity for brigade members to fulfill “community education” requirements.

• See the brigade manual for ideas.

• Possible ideas: Good nutrition, Hygiene, Hand washing

Point of Care Interventions

• Base nutritional state subjects children to more severe infections.

• Treat noted needs with the appropriate antibiotics, anti-parasitic therapies and ointments.

• Face to face interaction emphasizes our core value that every individual is important

Station 7: Clinician’s Station

• Consider this a brief well child exam• Take a history to determine acute or chronic

problems and address each problem.• Ask girls >11 about last menstrual period. (in

case of pregnancy, do not administer albendazole)

• Review results-z scores, visual acuity, HCT.

Station 8: Referrals

• Should usually include a Honduran staff member who is knowledgeable regarding local resources, upcoming brigades, and regional access to services.

• Refer:• Children with z scores<-2 (feeding program)• Visual acuity < 20/50 in both eyes separately, or <

20/50 with both eyes combined.• Special issues

Station 9: Medication Administration

• Antiparasite Treatment

• Vitamin A

• Multivitamins

• Other medications for acute illness

• Only give medications to parents (other than albendazole, Vitamin A and multivitamins) to ensure proper use and dosing.

Vitamin A Deficiency

• Affects >127 million preschool children • 1 to 3 million childhood deaths per year• Supplementation reduces all cause

mortality by 23%• Treatment decreases mortality from

measles, malaria, pneumonia, diarrhea

• [i] Miller, Melissa, Jean Humphrey, Elizabeth Johnson, Edmore Marinda, Ron Brookmeyer and Joanne Katz, “Why Do Children Become Vitamin A Deficient?” The Journal of Nutrition

Vitamin A Deficiency

Vitamin A Deficiency

• According to the WHO Global Database on Vitamin A Deficiency (2005-2006),  11 % of women, age 15-49 in Intibuca, reported xeropthalmia at some point in their lives.  This was the highest by far of all the departments in Honduras. 

Vitamin A Administration

• Dosage• 0-6 months: 50,000 IU• 6-11 months: 100,000 IU• 12-60 months: 200,000 IU

• Puncture liquid capsule with a needle, squirt in mouth of children

• Ask if children have received Vitamin A in the last 6 months.

• Should not be given to pregnant women

Zinc Deficiency

• May be single most important preventative supplement for children in the developing world. Robert Black

• Decreases length of diarrhea by 24%• Decreased treatment failure and death by 42%• Zinc supplementation has the same effect in

prevention of diarrhea as clean water and sanitation

• Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials1–3” The Zinc Investigators’ Collaborative Group, The American Journal of Nutrition

Zinc Administration

• Each child in the CHI receives a one month supply of children’s multivitamins twice yearly.

• Given at the medication administration station

Anti-Parasitic Treatment

• Increases health and productivity while decreasing death in the population.

• Periodic treatment in children, decreases the prevalence in the entire population.

• School absenteeism drops by 25%.[i]

[i] Kremer, Michael, and Edward Miguel, “Worms: Education and Health Externalities in Kenya” Poverty Action Lab Paper No. 6 September 2001

Anti-Parasitic Treatment

• Dosage• Age < 12 months Do not give• Age 12-24 months Albendazole 200 mg x 1• Age >2 yearsAlbendazole 400 mg x 1• If child has received in last 3 months, do not need

to give unless there are signs or symptoms of worms.

Results of the CHI So Far: 2008

• Number of visits: 4820

• US Volunteers >30%

• % children with stunting & wasting 4%

• % children with anemia 7%

• % children with decreased vision 12%

Results of the CHI So Far: 2008

• % children stunting (HAZ < -2)26%

• % children wasting (WAZ < -2) 18%

• Large number of families with food insecurity, therefore more food aid than expected needed