Tag Archives: counseling

Rehydration Unit

In the video, the Haitian child was listless: his eyes were sunken and his shriveled body was limp. His mouth curled, turtle-like, to prepare to cry, but no tears came. A gloved hand, arm hairs poking out, reached for the skin around the child’s abdomen. The hand of the clinician pulled gathered skin to form a sinusoid mound. Then, instead of snapping into place as skin normally does, the mound slowly melted back like silly putty. The words “SKIN PINCH” scrolled across the bottom of the video.

The skin pinch is one of the main diagnostic criteria for testing severe dehydration. In those severe cases in which the body has lost more than 15% of essential fluids, the little fluid left in the body rushes to the skin to cause the counterintuitive effect of swelling. Taped during a cholera epidemic in Haiti, the CDC video was showing how to best manage dehydration. The child had become severely dehydrated from the watery diarrhea that is a common and deadly symptom of cholera infection. By the end of the video, thanks to provision of the best possible treatment, the child was healthy and alert.

This “best practice” is something we are replicating in the slums of Fakir Bagan at Calcutta Kids with the new Rehydration Unit. The Rehydration Unit will allow us to tackle the terrible effects of diarrhea on the children under the age of three in our area. I reviewed over this CDC video to train our community health workers to diagnose and deliver key messages in the Rehydration Unit. One of our four main objectives at Calcutta Kids is to ensure that children age 0-3 grow normally. Diarrhea, the cause of fatal dehydration, is one of the central culprits in preventing normal growth, since it’s been linked to stunting and slower brain growth (1). Over the past six months, Sriya Srikrishnan (the other AIF Clinton Fellow) and I have been working to develop training modules for the health workers, a treatment protocol, and new counseling materials for the Rehydration Unit.

There is no reason any child should ever grow less or die from diarrhea. Yet this preventable and easily treatable disease takes 1.3 million under-five lives a year, a large proportion of those in India (over 1,000 daily on the subcontinent) (2). With counseling on hygiene practices, we can prevent diarrhea by stopping the root cause of microbial transmission. Additionally, the best treatment for diarrhea is the simple and cheap solution of “oral rehydration solution” or O.R.S.

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The Rehydration Unit is built on lessons learned from previous experiences with fighting diarrheal prevalence in Fakir Bagan. Back in 2010, analysis of the monthly growth monitoring and promotion weights showed a strong correlation between low weights and having had diarrhea in the two weeks before weighing. This connection spurred a desire to focus in on diarrhea, as both a cause and effect of malnutrition. After studying the highly successful model of the International Centre for Diarrhoeal Disease Research (icddr,b) in Bangladesh, Calcutta Kids opened up the Diarrheal Treatment Center (DTC) in March 2011.

This first foray into treating diarrhea was highly successful, but in creating the Rehydration Unit, we sought to learn from the weaknesses of the DTC initiative. Funded by a grant the World Bank, Calcutta Kids had rented a separate space with a separate staff roster dedicated to the DTC. For the Rehydration Unit, we’ve gone in a different direction. While retaining the essence of the DTC (O.R.S., Zinc, counseling), we wanted the Rehydration Unit to be an integrated part of the central initiative of Calcutta Kids: the Maternal and Young Child Health Initiative (MYCHI) in terms of funding and staff. Health workers, with whom the mothers of the community are familiar and have a rapport with, deliver the innovative BCC materials (from games to demonstrations) and conduct the follow-up visits in the home. Funding is no longer dependent on external grant cycles.

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Each 90-minute treatment at the Rehydration Unit has been divided into prevention and treatment modules for counseling. Along with counseling, we have adapted practices from the W.H.O on how to best manage diarrhea with O.R.S. and Zinc while learning from our experience with the Diarrhea Treatment Center. This combination of counseling and the clinical treatment at the Unit (all administered by the community health worker) allows us to treat the short-term problem of diarrhea and dehydration in the most effective way possible while changing behaviors to prevent diarrhea from occurring in the future. The protocol and rehydration unit checklist has been designed to include all these facets and create a conducive environment for health worker-mother interaction.

We have deliberately called the new unit, attached to our daily health clinic, a “rehydration” unit rather than a “diarrheal treatment” unit. Calcutta Kids is seeking to change perspectives on what the ideal treatment should be for diarrhea. Rather than treating diarrhea with anti-diarrheals or anti-microbials (as is common in most of India), the treatment at the Rehydration Unit calls for replacing the lost fluids with O.R.S. to restore the body’s fluid balance. O.R.S. is nothing more than a carefully balanced salt, sugar, water solution that restores the natural transport systems of the intestines. Despite its simplicity, it remains the gold standard for treating diarrhea. It’s discovery, like many scientific advancements, was accidental but fortunate.

In the early 1970s with the Bangladesh War of Independence raging, refugee camps were overflowing and cholera was highly prevalent. The standard treatment was “intravenous fluids while starving the gut,” but the clinical staff ran out of IV therapy. In these desperate circumstances, one Calcutta doctor, Dilip Mahalanabis, decided to try an untested and new treatment: O.R.S. Miraculously, the mortality rates dropped to 3.6% instead of the normal 30% to 40% with IV fluids (3). Calcutta Kids has had the good fortunate to spend time with Dr. Mahalanabis on a number of occasions and he advised us with the DTC.

In India, only 31% of doctors prescribe O.R.S. for diarrhea (4), and often antibiotics are overprescribed. The first component of the behavior change communication modules aims to change these perceptions in the mothers of Fakir Bagan, and hopefully enable the mothers to use O.R.S. themselves at home in cases of diarrhea.

Additionally, the causes of diarrheal incidence stem from improper health and hygiene behaviors as well as from lackluster systemic factors (in water and sanitation). Changing simple behaviors, including hand washing, food handling, toilet usage and disposal of feces, and exposure to open sewers and animal feces, can reduce diarrheal incidence enormously. Hand washing alone can reduce diarrheal incidence by up to 53% (5).

The Rehydration Unit is an example of the innovative and deep thinking way in which Calcutta Kids functions. Calcutta Kids is bringing the most effective, scientifically verified solutions to a community that needs them. Efforts like this will make child morbidity and mortality from diarrhea a fact of the past.–Pranav Reddy

Persuasion Dissected

Persuasion Dissected

(1)Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, et al. (2008) Multi-country analysis of the effects of diarrhoea on childhood stunting. International journal of epidemiology 37: 816–830.

(2) Santosham M, Chandran A, Fitzwater S, Fischer-Walker C, Baqui AH, Black R (2010) Progress and barriers for the control of diarrhoeal disease. Lancet 376: 63–67.

(3) Ruxin, JN (1994). “Magic bullet: the history of oral rehydration therapy”. Medical History 38 (4): 363–97.

(4) Taneja DK, Lal P, Aggarwal CS, Bansal A, Gogia V. Diarrhea
management in some Jhuggi clusters of Delhi. Indian Pediatr 1996;
33: 117–19.

(5) Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: A randomised controlled trial. Lancet 2005;366(9481):225-33.

The Story of Puja Yadav

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

Immunizations – More Than Just a Shot

The immunization program has been a service of Calcutta Kids for many years, but during the last year, we have worked very hard to make it as effective and efficient as our GMP program. There are two primary ways that we have accomplished this; the first is a short multimedia education and counseling session and the second is a system in our database that tracks the immunizations for each child and correctly identifies those who are eligible for that week’s clinic.

Rather than simply telling mothers and caretakers that these immunizations are necessary, we are working to inform our beneficiaries about why these immunizations are important. The short education and counseling session is designed to convey information on both the disease (or diseases) that the immunization is preventing, and on possible side effects. We have already seen mothers taking a larger interest in the immunization program and asking the CHWs about the next session. And for those not taking the initiative, we have an accurate list of all children who should come to the clinic and take the time to remind each household on that list. Take a look at the immunization counseling materials here.

The immunization section of the database has been greatly improved in the past year, and now takes into account the immunizations that have been received and the dates of each immunization received. This is important because many children have missed doses and are therefore off the ideal schedule. For example, a child may have received the first dose of DPT, OPV and Hep-B, but then did not receive the second dose after four weeks, but instead returned after eight weeks. According to the age, the child should be receiving the third dose but in fact, he or she should be receiving the second dose. The system also makes sure that enough time has passed between doses. These two improvements are helping us toward our goal of full immunization for each child that participates in our program. -Dora Levinson

Saving a Severely Malnourished Child

Ajay was born on August 20, 2011 in a village outside of Kolkata. Sadly, his mother died shortly after childbirth, and he was sent to be raised by an aunt, also in the village, who had two other children. Over time, Ajay grew malnourished and his aunt was unable to provide proper care for him. In late 2011, he was sent to live with another aunt named Pramila in Fakir Bagan, where we work. Pramila has been married for many years, but has never had any children of her own.

Ajay and Pramila in late January, 2012

Pramila learned about Calcutta Kids and on Friday, January 20, she brought Ajay in for his first immunizations at five months old. Our triage nurse was quickly alarmed; his distended stomach, loosely hanging skin, bulging eyes, skinny limbs, and lethargy made her nervous about the inoculation. Weighing in at 3.79kg (~8.4lbs), he had a weight-for-age Z-score (WAZ) of -5.392, which was off the growth charts in the severely malnourished category. Bringing him to the attention of our health workers and doctor, Ajay received a thorough examination and a counseling and nutrition plan began. Ajay’s dirty bottle and diluted cow’s milk were replaced with clean bottles and newborn formula. Thankfully, he was hungry and eager to recover.

Starting the following Monday, Pramila brought Ajay to the Swastha Kendra (health center) daily for supervised feeding of Ajay. CK mothers are always encouraged to exclusively breastfeed, but in this case, without a lactating mother and with the severity of Ajay’s malnutrition, formula became the only viable option. Thanks to generous donors, CK supplies Ajay with all of his formula, which is expensive but critical to his growth. Almost immediately, we also started complementing his formula feeding with kicheri (lentils, rice and vegetables), which he ate well. Our community health workers conducted regular home visits to make sure that feedings were successful in the home. By February 1, Ajay weighed 4.5kg (~9.9lbs), and had a WAZ of -4.49. Making great progress, he was looking healthier and had more energy.

Ajay in late February, 2012

Pramila was also taken in by our mother’s support group. They were eager to help her, and invited her to attend their meetings. At one meeting, they taught Pramila various ways to make household ingredients into baby food. As a first-time mother of a very fragile child, the women in the support group also took the initiative to visit her and make sure she had what she needed. On March 1 he weighed 5.7kg (~12.6lbs) and had a WAZ of -3.633. His cheeks and limbs were starting to fill out, he was able to roll over on his own, and his smile could light up a room.

Ajay and Pramila in late March, 2012

Ajay and Pramila have continued coming to Swastha Kendra 2-3 days per week for counseling and food. On March 20, two months after Ajay’s first visit to Calcutta Kids, he weighed 5.97kg (~13.2 lbs) with a WAZ of -2.95, and was officially out of the “severely malnourished” category. Throughout the whole process, Pramila has worked very hard, heeding the counsel of Calcutta Kids, and has expressed her gratitude for our programs.

Ajay and Pramila in late March, 2012

Sitting in Swastha Kendra, I am fortunate to be able to see Ajay and Pramila regularly, observing the feeding, assessing his progress, and enjoying their company. The transformation in this sweet child over these 2+ months has been remarkable to witness. Thanks to the great work of Calcutta Kids, he continues to grow well, and is reaching both physical and developmental milestones. – Margy Elliott, Fellow, American India Foundation

Flip-Charts, Training and a Community Center – Oh MY(CHI)!

Originally posted in the Fall 2011 Newsletter

The Maternal and Young Child Health Initiative (MYCHI) staff has been working diligently over the past nine months to make our programs even more effective. Danya and Sumana have been revising the pregnancy care program to reflect changes in international maternal and neonatal health guidelines and to utilize the lessons we have learned over the past 6 years. We now have two excellent flip charts that are culturally appropriate to help counsel families about best practices and the early detection of problems.

In May, we had an in-depth training on the new pregnancy care program with all of our community health workers and other MYCHI staff. In this training, we were able to explain exactly why each type of data is collected; to provide refresher information on the complications that can occur during pregnancy, delivery and the first few months of life; and to talk through specific problems that have arisen in our area. In the course of the training, we also were able to strengthen the bonds that have enabled us to work as a team and to have fun together!

We are also working to revise the child health program to better tackle the non-food related causes of malnutrition as well as to update the program more generally. During the past six months, we worked with a small sample of severely malnourished children to find out with precision the causes of their malnutrition. We found that many of these children were suffering from anemia, a high worm load, several micronutrient deficiencies and stress in the home, all of which hinder the absorption of nutrients and, in turn, impede affect mental and physical development. We now can use this information to inform our protocols as we redesign the child health program. We are very excited about the new community center, located in Fakir Bagan itself, which will be opening in December – a safe, clean and attractive site where we can hold our regular community meetings and gatherings of small support groups – a space for women and children to come together comfortably for support and information.