The Role of Pediatric Gastroenterology and Nutrition in Developing Countries

Diarrhea and malnutrition are on the top-10 list of the causes of morbidity/mortality in children under 5 years of age in developing countries. Diarrhea and malnutrition have also been prioritized topics in pediatrics programs directed towards third world countries. Diarrhea is usually addressed with acute treatment algorithms and nutrition is treated as a community-based preventive program. What about the role of the subspecialty of gastroenterology and nutrition in the developing world? Is the discipline too sophisticated for the medical needs of third world countries? Are the simplified algorithms and preventive programs enough? Should there be more interactions between academic departments and public health programs? These questions arose very early during my recent years working at the Pediatric Department in Maputo, Mozambique. MOZAMBIQUE Mozambique is a typical developing country in sub-Saharan Africa. One year after independence from Portuguese colonial rule in 1975, Mozambique had approximately 100 physicians, of whom fewer than 10 were Mozambican natives. In 2004, with 400 national doctors for a population of 18 million, Mozambique still has an extremely low number of doctors per person. Some 25 Mozambican doctors are currently training in pediatrics. During my time in Mozambique, four of the 10 provinces got newly graduated pediatricians. The vast majority of the population never sees a doctor; many never even see a trained nurse in response to health complaints, although some services, such as childhood immunization, are widely available. Medicine in Mozambique has four faces. First, there is the governmental health system whose physicians and nurses provide services to the general population at hospitals and health centers. At Mozambiquan government health centers the personnel have rudimentary training. Some of the physicians are extremely well trained but salaries are low. Second, there are multilateral organizations (mainly UNICEF and the World Health Organization, WHO) acting within the governmental system and a small number of non-governmental organizations. These organizations are funded externally and advocate for and support preventive health and primary health care with standardized algorithms and modes of treatment. Third, there is a small but growing private sector serving the wealthiest segment of the population. Trained health personnel in the larger cities can significantly improve their salaries by working off-hours in these clinics. Finally, there are traditional healers, who still provide care for the majority of the population. The curriculum for the training of doctors is very close to the European curriculum. However, pre and postgraduate schooling cover mainly community approaches to nutrition and diarrhea, and other aspects of gastroenterology and nutrition are scarcely dealt with. Other than treatment of severe malnutrition, other nutritional topics are not taught. Diarrheal Diseases versus Gastroenterology The use of oral rehydration solution therapy for acute diarrhea constitutes a major public health advance in the developing world in the last 30 years. Since the classic article on the efficacy of oral rehydration solution was published, the global mortality from acute diarrhea has decreased from 5 to 1.8 million per year. In Mozambique, 77% of all mothers know about oral rehydration solutions and 50% of all children get oral rehydration solution made from a package when having diarrhea. The success with oral rehydration solution, the refinements in its composition, and its widespread application (1) are the result of an interactive process between researchers and international organizations. WHO has, through programs such as CDD and IMCI, advocated the usage of oral rehydration. The earlier CDD program was a symptom-oriented program that achieved a widespread increase in the understanding of the application of oral rehydration in the last two decades. In the IMCI approach, there is a more integrated assessment and treatment of the sick child by health professionals at different levels in developing countries. The project focuses on systemic capacity for predictable routine and referral care and when fully implemented includes a process for monitoring the quality of care. There are special modules for each of the main health problems of children, including guidelines for the treatment of severe malnutrition. Whereas the treatment of acute diarrhea is relatively straightforward, dealing with malnourished patients or patients with persistent diarrhea is more complicated. The WHO-recommended modified formula for the treatment of malnourished children with diarrhea has only recently been studied and the clinical results are not too impressive (2). Ten % of diarrheal illness in children from developing countries is classified as chronic, prolonged, or persistent. The mortality is high (30%). Diagnosing and treating prolonged diarrhea is very different from the treatment of acute diarrhea. Treatment of chronic diarrhea requires more than adherence to a simple algorithm. It requires medical personnel with a deeper knowledge of gastroenterology and intestinal function. Malnutrition versus Nutrition Around 50% of the under-5 mortality in developing countries is estimated to be related to malnutrition. A 1997 survey in Mozambique showed that the under-5 mortality was 201 per 1000 live born children, and that 44% of these deaths were related to malnutrition. Some 33% were related to moderate malnutrition and only 11% to severe malnutrition. Despite these results, only severe malnutrition has a place in strategic programs such as WHO/IMCI. The approach to treatment of severe malnutrition has been very efficient, but these existing treatment programs deal with only a minority of the malnourished children in hospitals and medical settings. Sadly, nutritional problems in patients are tolerated to a far greater extent in countries with high mortality resulting from nutritional disorders than in those countries where malnutrition is rarer and less deadly. It could be argued that the cut-off for treatment should be different in a country such as Mozambique. But a more proactive treatment of children with moderate rather than severe malnutrition is probably more cost effective and would greatly improve the survival (3). Growth charts in the developing world only indicate weight for age because this is regarded as a good measurement of the nutritional status in a community. However, when children come to the hospital, the weight-for-height concept should be used to identify acute malnutrition. If not, children with moderate wasting are bound to be missed. Nutritional treatment is only directed to the severely malnourished, and the use of enteral nutrition made of local ingredients is often an overlooked possibility to treat children with impaired gut function. Good clinical nutrition goes beyond preventive community programs and needs to use appropriate tools for identification of patients that can improve the ability to detect treatable conditions. HIV HIV infection, now so prevalent in Southern Africa, has changed the face of medical care and has increased the importance of pediatric gastroenterology and nutrition. HIV sooner or later affects the nutritional status and gut function of its victims. Children infected early with HIV have a survival rate at 5 years of age of 38%. Only a third of the children who die before the age of 5 meet the full AIDS criteria. They die of malnutrition, diarrhea and/or pneumonia. Failure to thrive is the most frequent sign of disease in an HIV-infected child, whereas diarrhea is the sixth most frequent sign. Undernutrition accelerates the progression of HIV disease. Nutritional intervention may restore intestinal absorption and increase CD4 cell numbers. The efficacy of nutritional intervention is enhanced if provided before HIV reaches an advanced stage. Diarrhea is a late symptom in an HIV-positive child, but when it starts, it is a difficult problem to counteract. Although a number of studies have been published on gut function in HIV, there are few on children. So far there are no distinct recommendations for investigation, monitoring or treatment of children living with HIV. If the new "3 by 5 strategy" launched by WHO becomes a reality, 3 million people with HIV will receive antiretroviral treatment by 2005. Clinicians using antiretroviral treatment will surely need the perspective on nutrition offered by modern gastroenterology. Antiretroviral treatment also has effects on the gut function. So far there have only been a few recommendations on nutrition and HIV, some of which unfortunately testify to a complete lack of knowledge in this area (4). Children living with HIV need nutritional support. The means by which to prevent or treat impaired intestinal function must be established. To wait for symptoms is to lose the opportunity for possible positive intervention. Recommendations for gastroenterological and nutritional support for HIV-affected children with and without antiretroviral treatment are still pending. Whose Problem is it, Anyway? Pediatric gastroenterology and nutrition in third world medicine has been reduced to simplified treatment schedules for acute diarrhea, severe malnutrition and preventive nutritional programs. For the vast majority in countries like Mozambique, the universal use of algorithms for common diseases at a primary health care level would be a great improvement. There is no doubt that when IMCI programs are fully implemented at this level, it will save and improve life. What about the capacity to go beyond the algorithms? Today there is a disconnect between physicians and the algorithms which are developed to be used by untrained personnel. The young doctors are trained by WHO/UNICEF. They in turn train other health staffs in the appropriate application of treatment algorithms. They follow the carefully written instructions during the training, but often grow to regard the models as too simplified to be used by physicians and treat their patients individually despite their lack of deeper knowledge of gastroenterology and nutrition. To improve the survival rate of children with prolonged diarrhea and gut impairment resulting from malnutrition and HIV, gastroenterology has to become a priority discipline in third world physician training. The national medical professionals need the knowledge tools or our discipline in order to determine how best to use scarce resources and how to incorporate the algorithms into their academic training. The further development of both rehydration solutions and enteral nutrition depends on the clinical use and elaborations in hospital settings in third world countries. The governments in third world countries are responsible for the development of appropriate programs in pediatric gastroenterology and nutrition. Medical societies in these countries need to acknowledge implementation of locally adapted approaches and not merely copy medicine in the developed world. The donor community should not overlook the need for a healthy development of clinical medicine because primary health care is not a panacea for better health in poor countries. In particular, international organizations need to move beyond algorithms. Introduction of simplified treatment schedules should be connected to the academic health professionals, as research and/or quality of care studies. Nationalized experiences will deepen the understanding and improve the utility rate. No recommendations in this area (2,4) should be widely applied before before being scientifically analyzed and professionally revised. Without a pediatric gastroenterology/nutrition approach, the new WHO strategies for the combat of HIV will be an incomplete program. Lena Grahnquist, M.D., PhD. Department of Women and Child Health, Karolinska; Institutet and Pediatric; Gastroenterology and Nutrition; Astrid Lindgren Children's Hospital; Stockholm, Sweden

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