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"Child`s Health" 1 (69) 2016

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Peculiarities of Teaching the Topic «Protein-Energy Malnutrition in Children» to English-Speaking Students

Authors: Kuznetsova O.D. - Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Summary

В статье отражены проблемы, возникающие в процессе преподавания темы «Белково-энергетическая недостаточность у детей» англоязычным студентам. Освещены отличия протоколов разных стран, в частности приведен сравнительный анализ терминологических понятий «гипотрофия», «белково-энергетическая недостаточность» и under nutrition, stunting, acute, сhronic malnutrition, wasting, kwashiorkor, указаны антропометрические показатели для оценки тяжести дефицита питания (дополнительно используется Mid-Upper Arm Circumference), приведены антропометрические критерии диагностики степени тяжести белково-энергетической недостаточности и группы риска по ее развитию. Описаны вопросы ведения пациентов с тяжелым и умеренным нарушением питания согласно зарубежным документам, представлена дифференциальная таблица выбора типа лечения ребенка с тяжелым нарушением питания, освещены принципы, фазы и стадии лечения, особенности ведения пациентов с использованием продуктов, готовых к употреблению (ready to use therapeutic food). Анализ протоколов Украины, Всемирной организации здравоохранения, Индии, Кении позволил адаптировать методику преподавания указанной темы англоязычным студентам.

У статті знайшли відображення проблеми, що виникають у процесі викладання теми «Білково-енергетична недостатність у дітей» англомовним студентам. Освітлені відмінності протоколів різних країн, зокрема наведений порівняльний аналіз термінологічних понять «гіпотрофія», «білково-енергетична недостатність» і under nutrition, stunting, acute, сhronic malnutrition, wasting, kwashiorkor, вказані антропометричні показники для оцінки тяжкості дефіциту харчування (додатково використовується Mid-Upper Arm Circumference), наведені антропометричні критерії діагностики ступеня тяжкості білково-енергетичної недостатності та групи ризику її розвитку. Описані питання ведення пацієнтів із тяжким і помірним порушенням харчування згідно із зарубіжними документами, наведена диференційна таблиця вибору типу лікування дитини з тяжким порушенням харчування, освітлені принципи, фази і стадії лікування, особливості ведення пацієнтів із використанням продуктів, готових до вживання (ready to use therapeutic food). Аналіз протоколів України, Всесвітньої організації охорони здоров’я, Індії, Кенії дозволив адаптувати методику викладання вказаної теми англомовним студентам.

The problems that arise during the process of teaching the topic «Protein-energy malnutrition in children» to the English-speaking students are discussed in this article. It highlights the differences in the protocols of various countries, in particular presents the comparative analysis of terminological concepts of hypotrophy, protein-energy malnutrition, undernutrition, stunting, acute, chronic malnutrition, wasting, kwashiorkor, provides anthropometric indicators to assess the severity of inanition (optional use of Mid-Upper Arm Circumference), gives anthropometric criteria to diagnose the severity of protein-energy malnutrition and the group at risk for its development. The article describes the issues of managing patients with severe and moderate malnutrition according to foreign documents, presents the differential table for the choice of treatment of a child with severe malnutrition, highlights the principles, phases and stages of treatment, features of mana­ging patients with the use of products ready for use (ready to use therapeutic food). Analysis of protocol of Ukraine, the World Health Organization, India, Kenya has allowed to adapt me­thods of teaching this topic to English-speaking students.


Keywords

дети, недостаточность питания, англоязычные студенты, преподавание.

діти, недостатність харчування, англомовні студенти, викладання.

children, undernutrition, English-speaking students, teaching.

Introduction. The trend of increasing the number of foreign students in recent years poses teachers tasks that will improve the quality of students training and, as a consequence, will raise the rating of the university on the international arena. The multinational composition of students originating mainly from African countries (Nigeria, Zambia, Morocco, Kenya) and Asia (India) and interstate differences in guidelines of integrated management of patients with certain diseases dictates the need to adapt teaching methodology of individual pediatric topics on IV course, particularly, "protein-energy malnutrition in children."

According to the World Health Organization in 2011 up to 70% of children suffering from malnutrition live in Asia and Africa. At the same time 2.2 million children die each year from malnutrition. Mortality rates in wasting are 20-30%, in kwashiorkor - 50-60%.

Objective: To show the teaching peculiarities of topic "Protein-energy malnutrition" to English-speaking students on IV course based on the study of differences existing in protocols and guidelines of different countries.

Materials: the protocol Ministry of Health of Ukraine №149 from 20.03.2008 "Medical surveillance of healthy children under 3 years of age", the report of Ministry of Health of Ukraine № 9 from 10 January 2005 "Treatment of malnourished children», The National Guideline for Integrated Management of Acute malnutrition: Kenia (2009), ACF-In Guidelines for the integrated management of SAM (2011), Guideline: updates on the management of severe acute malnutrition in infants and children (WHO, 2013), Integrated Management of Acute Malnutrition Guidelines (Ministry of Health of Uganda republic, 2010).

Firstly it is rational to discuss terminological differences. Thus term “protein-energy malnutrition” is no longer used in American, African and WHO protocols as it is not thought that protein or energy deficiency, are the usual causes of severe acute malnutrition. Under nutrition is a “catch-all” term for a deficiency of any of the essential nutrients (protein, essential fatty acids, electrolytes, minerals and vitamins) or energy. It not only encompasses stunting, wasting (type II deficiency) but also clinical illness brought about by deficiencies of any of the specific essential nutrients which may not be associated with any anthropometric change (and can occur in obese people). Under weight - indicates when a child has a low weight for his/her age. Acute malnutrition involve wasting (occurs when a person has lost weight and become excessively thin) and kwashiorkor (a clinical syndrome characterised by bilateral oedema. It is often also associated with lesions of the skin, fatty liver, atrophy of the organs and mental changes).

         In Ukrainian protocols physical development assessment is based on antropometric measurements of weight, height, calculation of body mass index, weight / height ratio, but MUAC (Mid-Upper Arm Circumference) is not used. The other way, admission criteria in WHO, Kenia, India guidelines to determine in-patient or out-patient care are based in particular on MUAC (Mid-Upper Arm Circumference) and W/H (weight-to-height) ratio values, as well as on presence of bilateral oedema, medical complications, results of appetite test, suitable and willing caregiver. In addition, the classification of malnutrition according to the protocol Ministry of Health of Ukraine № 9 in 2005 takes into account the percentage of weight deficiency, which is not applied in foreign protocols that require exclusion of this issue from the plan of topic preparation of foreign students.

Patients without complications and with good appetite may go directly for out-patient treatment. It is important to conduct an Appetite Test which is not used by Ukrainian pediatricians; therefore, we consider it appropriate to include a question about the appetite test in the theoretical part of the lesson plan for foreign students. The management of severe acute malnutrition in the in-patient setting is divided into three phases: Phase 1, Transition Phase and Phase 2, which are conducted according to 10 steps: correction of Hypoglycemia, Hypothermia, Dehydration, Electrolytes disturbances, Infection prevention or treatment, Micronutrients replenishment, Cautious feeding, Catch-up growth, Sensory stimulation, Prepare for follow-up.

Differences of malnutrition management in Europe, Africa and America from Ukrainian protocols are: availability of ready to use therapeutic products (RUTF) that does not require cooking, with the fixed content of proteins, fats, carbohydrates and calories, as well as the presence of clear indications and steps in the treatment of severe and moderate malnutrition. RUTF are approved by the World Health Organization. They are produced in some African countries such as Nigeria, Congo, and Ethiopia. The introduction of RUTF optimize the treatment of malnutrition. Basic information on the products can be found on the website http://www.nutriset.fr/en/homepage-nutriset.html, which is given to foreign students on faculty pediatrics department for information.

In the current Ukrainian protocol there is no differentiation on in-patient, outpatient treatment, detailed algorithm is absent. The protocol contains information that is not used in English literature and documents, for example, the calculation of the required quantity of fats, proteins, carbohydrates when treating malnutrition. It is also necessary to take into account the absence of drugs Oralit, Regidron etc.abroad.

The above differences disharmonized the methodical preparation of the topic to international students. Therefore, the preparation of the topic "protein-energy malnutrition" it is necessary to optimize the learning process by adapting European and African protocols and compiling them according to the test and situational tasks for students of international faculty.

Conclusion. When preparing the topic "protein-energy malnutrition in children" for foreign students of IV course, special attention should be paid to the terminology, including changing the topic name; on clinical features of kwashiorkor and wasting, their differential diagnosis; methodology of performing the appetite test. A clear formulation of admission and discharge indications must be covered. In the treatment part of the lesson students should master the 10 malnutrition treatment steps, phases of treatment in the hospital and out-patient departments; classification of RUTF, basic products (F75, F100, PlumpyNut, Resomal). Clinical part of the classes should be added with procedure of Mid-Upper arm circumference measurement.


Bibliography

1. Бабцев А.Ф. Гипотрофия у детей [учебное пособие] / А.Ф. Бабцев, Т.Е. Бойченко, О.В. Шанов. — Благовещенск: Буквица, 2011. — 22 с.

2. Скворцова В.А. Нарушение питания у детей раннего возраста / В.А. Скворцова, О.К. Нетребенко, Т.Э. Боровик // Лечащий врач. — 2011. — № 1. — С. 26-31.

3. ACF-In Guidelines for the integrated management of SAM: in and out-patient treatment / M.H. Golden, Y. Grellety [et al.] // Режим доступа: http://www.actionagainsthunger.org/sites/default/files/publications

4. Bergeron G. Program Responses to Acute and Chronic Malnutrition: Divergences and Convergences / G. Bergeron, T. Castleman // Adv. Nutr. — 2012. — Vol. 3. — P. 242-249.

5. Efficacy of modified WHO feeding protocol for management of severe malnutrition in children: a pilot study from a teaching hospital in New Delhi, India / Parakh A. [et al.] // Asia Pac. J. Clin. Nutr. — 2008. — Vol. 17(4). — P. 608-661.

6. Incidence and duration of severe wasting in two African populations / Garenne M. [et al.] // Public. Health Nutr. — 2009. — Vol. 12(11). — P. 1974-1982.

7. The National Guideline for Integrated Management of Acute Malnutrition (Kenia, 2009) / Dr. Francis Kimani, S.K. Sharif // Режим доступа: www.cmamforum.org/pool/ kenya-moh-imam-guideline-june-2009.pdf

8. UNICEF-WHO-The World Bank Joint Child Malnutrition Estimates [Електронний ресурс]. — Режим доступа: http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf

9. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. — Geneva: World Health Organization, 2013. — Режим доступа: http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/


1.      Babtsev AF, Boychenko TE, Shanov OV. [Malnutririon in children [uchebnoe posobie]. Blagoveschensk: Bukvitsa. 2011: 22 s.

2.      Skvortsova VA, Netrebenko  OK, Borovik TE [Nutrition disorders in children of early age group]. Lechaschiy vrach. 2011;  1: 26-31.

3.      ACF-In Guidelines for the integrated management of SAM: in and out-patient treatment / Michael H Golden, Yvonne Grellety [et al.] // rezhim dostupa http://www.actionagainsthunger.org/sites/default/files/publications

4.      Bergeron G., Castleman T. [Program Responses to Acute and Chronic Malnutrition: Divergences and Convergences] . Adv Nutr .2012; 3:242-249.

5.      Efficacy of modified WHO feeding protocol for management of severe malnutrition in children: a pilot study from a teaching hospital in New Delhi, India / Parakh A. [et al.] // Asia Pac. J. Clin. Nutr. – 2008. – Vol. 17(4). – P. 608-661.

6.      Incidence and duration of severe wasting in two African populations / Garenne M. [et al.] // Public Health Nutr. – 2009. – vol. 12(11). – P. 1974-1982.

7.      The National Guideline for Integrated Management of Acute Malnutrition (Kenia, 2009) / Dr. Francis Kimani, S.K. Sharif. – rezhim dostupa www.cmamforum.org/pool/ kenya-moh-imam-guideline-june-2009.pdf

8.      UNICEF-WHO-The World Bank Joint Child Malnutrition Estimates [web source]. – rezhim dostupa http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf

9.      WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children (Geneva: World Health Organization) 2013. - rezhim dostupa http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/

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