|CHILD HEALTH IN THE HINTERLANDS
|Year : 2021 | Volume
| Issue : 1 | Page : 67-69
A child with tuberculosis and severe acute malnutrition
Pavitra Mohan, Sanjana Brahmawar Mohan, Gargi Goel
Basic Health Care Services, Udaipur, Rajasthan, India
|Date of Submission||17-Oct-2020|
|Date of Decision||24-Oct-2020|
|Date of Acceptance||30-Oct-2020|
|Date of Web Publication||27-Feb-2021|
Dr. Pavitra Mohan
Basic Health Care Services, 39, Krishna Colony, Bedla Road, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mohan P, Mohan SB, Goel G. A child with tuberculosis and severe acute malnutrition. Indian Pediatr Case Rep 2021;1:67-9
We run a network of six not-for-profit primary healthcare clinics for remote, rural, and high migration communities in Udaipur district, South Rajasthan. Named AMRIT Clinics, they provide preventive, promotive, and curative health care to isolated populations of around 12000 each. More than 90% of the population is tribal, who live in dispersed settlements in hilly terrains. At least one male family member from about 60% households has migrated to a city (usually in Gujarat or Maharashtra), to earn his livelihood and support his family from afar. Not surprisingly, their circumstances are grim; food is scarce and medical illnesses run rife.
Communicable diseases such as tuberculosis (TB), diarrhea, pneumonia, and malaria; and noncommunicable diseases such as chronic obstructive pulmonary disease, hypertension, and diabetes are common reasons for visits to the clinic. Women additionally seek care for reproductive health needs (contraception, childbirth, and medical abortion). About 1 in 3 mothers report a child death, still birth or an abortion in the past. About half the children are malnourished, but are brought to seek treatment for associated complications.
In the course of managing these clinics, we witness unique issues surrounding child health that require a different paradigm for understanding and management, compared to the usual mainstream pediatric practice. Since a large proportion of avoidable childhood deaths and much of the morbidity of Indian children arise from such areas, it is critical to make these invisible children and invisible issues visible to all those who care for children. We present this particular case to highlight a community-based and a family-centered approach to manage childhood diseases and severe malnutrition.
| Case Study|| |
A 12-month-old tribal girl presented to us with decreased eating, diminished activity and a condition described by her mother as “shrivelling-up” since a month. There was no history of cough, breathing difficulty, or fever. She was being breastfed, and would additionally be given a few crumbs of roti through the day. Her mother's pregnancy had been uneventful and she was born normally, at home. She had started sitting at around 10 months, and could not stand or walk at the time of presentation. She was the second child of her parents; and her mother had also suffered a spontaneous abortion earlier. The child was immunized for date, including for measles. Her father had been diagnosed with TB and was on anti-tubercular treatment (ATT) since past 3 months. He was a daily wage laborer who had not been able to earn for several months due to his illness. The family lived in a remote hamlet on the hills, about 5 km from our clinic, about 20 km from the nearest functional primary health center, and 60 km from the nearest hospital. The family owned about 1 bigha (one-third of an acre) of unirrigated land. The family had no mobile telephone connection. The mother had come to the clinic walking, carrying the infant.
The child appeared lethargic and disinterested in the surroundings, but did display intermittent bouts of irritability. She had a respiratory rate of 34 per minute and her temperature was normal. She weighed 5300 g and measured 65 cm in length, which translated to severe wasting with a Weight for height Z score (WHZ) <-3. General physical examination revealed pallor, conjunctival xerosis, severe visible wasting, and 3 discrete deep cervical lymph nodes (each 0.5 cm × 0.5 cm). A BCG scar was evident on her left upper arm. There was no pedal edema. The abdomen was protuberant, soft, and had no hepatosplenomegaly. Other systemic examination was within normal limits. Based on this clinical evaluation, a diagnosis of severe acute malnutrition (SAM) with anemia was assigned. In view of the nutritional status and significant family history, comorbid TB was also suspected. While eliciting history from the mother, it was noted that she also appeared ill. On further enquiry, it was found that she had a history of cough and low-grade fever for the past month. Although there was no respiratory difficulty, she had been experiencing loss of appetite and excessive tiredness for a month or so. Her vitals were stable. She weighed 36 Kg (body mass index 17 kg/m2) and was pale. Respiratory examination revealed bronchial breathing in the right infraclavicular region.
We ordered the clinically relevant laboratory tests that are available in the AMRIT clinics. Blood glucose levels were normal. The hemoglobin levels of mother and child were 7.8 and 8 g/dL, respectively. A Mantoux test and chest radiograph (CXR) were done for the child. A sputum examination for acid-fast bacilli (AFB), CXR, and HIV test was ordered for the mother. We initiated a course of an oral antibiotics for the child and gave her a therapeutic dose of Vitamin A. We initiated her nutritional rehabilitation using ready-to-use-therapeutic-food (RUTF). In view of contact with TB in the household, she was also started INH prophylaxis, pending her investigations. We counseled her mother on improved feeding using RUTF and home available foods. The mother was also started on oral antibiotics.
In the next visit to the physician next week, the child's Mantoux test (read after 2 days of administration) was reported as 8 mm of transverse induration. The CXR showed right-sided hilar lymphadenopathy. Making a final diagnosis of SAM with pulmonary TB, we shifted her to standard protocol ATT, continued RUTF, and initiated iron supplementation. The mother's CXR revealed right upper lobe consolidation, sputum sample showed AFB (+), and HIV test was negative. Keeping the mother's diagnosis as Pulmonary TB and nutritional status as “underweight,” she was started on ATT and provided with “AMRIT Aahar,” a nutritious food supplementation package. This contains raw food items that provide 730 calories and 40 g proteins every day. It is given to all adult patients with TB fortnightly, and is continued throughout the course of treatment.
Over the next 2 months, the child suffered two acute illnesses; an episode of dysentery and a bout of mixed malaria (Plasmodium vivax and Plasmodium falciparum). She recovered from both with appropriate treatment, though her weight dropped on both occasions. The mother displayed gradual resolution of symptoms. After completing the intensive phase, the mother failed to pick up their ATT twice (for about 15 days each), due to involvement in harvesting. In both instances, the health workers identified this loss to follow up in time, and made home visits. The mother-child duo were provided with medication to avoid treatment default, and encouraged to continue visiting the clinic for completion of the maintenance phase.
Eight months after initial presentation, the girl weighed 6835 g (a weight gain of 1535 g), her hemoglobin had risen to 12 g, and she had become playful and active. As per standard TB protocol, we discontinued ATT, but continued nutritional counseling. Her parents had also completed their treatment and were disease free. Four months later, her weight was 7.5 kg and WHZ >-2. As you can see from her latest photograph [Figure 1], she continues to thrive. Her mother looks healthy and happy too.
| Discussion|| |
We would like to highlight three paradigm shifts for providing child health care in rural areas. The first shift is from individual centered care to family centered care. The child health is closely linked to the health and well-being of all family members. SAM and childhood TB often reflects an underlying deprivation in the family. Inability to or neglecting to identify the impact of such deprivation in other family members is unacceptable, and may even be considered unethical. In this case, if the mother had not been simultaneously screened and managed, she would have developed advanced disease and the impact on the entire family would have been adverse. In the broadest scope, the notion of family-centered care embraces the view of the care-client as the patient and their family, rather than just the patient.
The second shift is from individual disease focused care to integrated care. The Integrated Management of Newborn and Childhood Illnesses approach promotes an integrated approach to identification and management of childhood illnesses. There is ample evidence that a significant proportion of children with SAM have underlying TB, and if not actively screened for, are easy to miss. Such children are likely to take longer to recover and have higher mortality. Despite the awareness of co-existence and mutual reinforcement of SAM and TB, and existence of individual national treatment guidelines,, actively looking for and/or recognizing TB in a child with SAM, or SAM in a child with TB, is still a major challenge, unless management is facility based. This leads to inadequate and unsustained health care gains, and does not improve the overall well-being of the child.
The third shift is from centralized, hospital-based care, to decentralized, community-based care. It is common knowledge that there is paucity of health-care facilities and personnel in the periphery, especially the hinterlands. In this case, the clinics were located within the communities and were close to where the people lived, which allowed the family to access continued care. Besides, the health workers were able to follow-up the family by home visits, and thus prevented dropout. Furthermore, community-based management of SAM allowed continuity of care without hospitalization which prevented disruption of life and already precarious livelihoods. If such a care was only available in distant hospitals, the family may not have been able to access, leave alone sustaining the care. Of course, there are situations where children with SAM require hospitalization and advanced care, but if care can be provided closer to home, there is more likelihood that vulnerable families residing in such areas can, and will access it.
Finally, we wish to highlight the harsh realities of family, terrain, and society within which a large population of children in rural India reside. In this case for example, land and food scarcity, multiple morbidities within the family and distance from health facilities, all contributed to the child's ill health.
Should pediatricians, as a community, be bothered about these circumstances and conditions that affect child health in the hinterland? We leave that question for the readers to ponder over.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
The clinic in which this child was managed is supported through a grant by Great Eastern Shipping Company, through their CSR unit.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mohan P, Jain P, Agarwal, K. Child malnutrition in Rajasthan. A study of Tribal, migrant communities. Economic and Political Weekly. 2016; 51:73-81.
Gilmer MJ. Pediatric palliative care. Crit Care Nurs Clin North Am 2002;14:207-14.
Devan J, Ezekiel M. Childhood tuberculosis and malnutrition. J Infect Dis 2012;206:1809-15.
Ministry of Health and Family Welfare, Government of India. Operational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition; 2011.