Preterm babies don’t gain growth by early initiation of complementary food


Babies started early on complementary food tend to suffer more due to diarrhoea and lower tract infections.

Babies born preterm (before 37 completed weeks of gestation) have a higher energy requirement than babies born full term and therefore fail to gain weight adequately. Parents of preterm babies and doctors alike are not sure whether breast milk or formula milk alone will meet the energy requirements after the first four months and whether preterm babies should be started on complementary food. While normal babies are given solids and semi-solids only from six months of age, early initiation of complementary food, which has a higher calorie density, in preterm babies appears to be a good idea to meet their energy needs and improve their growth (weight and length).

Till recently there was little evidence of whether earlier introduction of complementary feeding (prior to six months of corrected age) would improve growth of preterm babies.

No gain in growth

A study published a few days ago in The Lancet Global Health has found an answer to this vexatious issue — early initiation of complementary feeding in preterm babies born before 34 weeks of gestation does not improve growth.

Doctors from the All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital and Kasturba Hospital, all in New Delhi, enrolled 403 babies born before 34 weeks of gestation and randomly assigned them to two groups — one in which they were started on complementary feeding at four months of corrected age and the other group of babies where complementary feeding was initiated at six months of corrected age. The corrected age refers to age that is corrected for the period of prematurity — for a baby born at 32 weeks of gestation, which is approximately two months earlier than the normal gestation period, the corrected age is 10 months at the end of one year of birth.

Complementary feeding was standardised in both the groups in terms of frequency, consistency, type of food, preparing food hygienically, and ways of feeding. Complementary foods were given in addition to breastfeeding/other milk feeding.

“Even though one group of babies was started on complementary feeding at an earlier age of four months of corrected age, there was no difference in growth compared with babies who were started on complementary feeding at six months of corrected age,” says Dr. Ramesh Agarwal from the Department of Paediatrics at AIIMS, one of the corresponding authors of the paper.

Some health risks

On the other hand, the study indicates that early initiation of complementary feeding had some negative fallout. “There were more hospitalisations in the group that started on complementary feeding at four months of corrected age,” he says. Though overall hospital admission in both the groups was low, babies in the four-month group were at increased risk of hospital admission due to diarrhoea and lower respiratory tract infections. “There could be several reasons for this increased risk, including potential contamination of complementary foods due to inadequate hygiene or having less breast milk,” he says.

“Our study shows that there is no difference in growth whether complementary feeding is started at four or six months of corrected age. But there are more infections when complementary feeding is started earlier. So it is advisable that complementary feeding is started only at six months of corrected age in preterm babies less than 34 weeks of gestation,” says Dr. Agarwal. However, studying the difference in growth and not infection was the primary objective of the study.

Published in The Hindu on May 7, 2017

Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?


The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Indian researchers turn to zebrafish to study microvillus inclusion disease


The intestinal defects in zebrafish are identical to humans. – Photo: Mahendra Sonawana

Indian researchers have finally found an ideal animal model to study microvillus inclusion disease (MVID) that may affect children born out of consanguineous marriages and to screen potential drugs to treat the disease. Currently, children with MVID disease have no treatment and mostly die premature as babies as they suffer from malabsorption of nutrients and huge fluid loss due to chronic diarrhoea.

Working with zebrafish a few years ago, Dr. Mahendra Sonawane from Mumbai’s Tata Institute of Fundamental Research (TIFR) and his team showed that mutations in myosin Vb gene lead to defects in epidermis development. But the epidermis defect gets partially resolved and the mutant fishes start growing normally before eventually dying 12-15 days after birth. “We did not know why these mutant fishes were dying. We suspected that there must be a defect in the intestine,” says Dr. Sonawane.

In humans, mutations in the myosin Vb gene have been linked to microvillus inclusion disease. This gene encodes for a protein that acts as a motor to transport small vesicles that carry proteins and secretary material from the inner part of the cell to the cell membrane or outside the cells.

Aside from the link to MVID, the gene is expressed in the intestinal epithelium of zebrafish.  So Dr. Sonawane’s team started looking for the morphology of the intestine when the myosin Vb function is lost due to mutations. The results of the study were published recently in the journal Mechanisms of Development.

The scientists expected zebrafish with the myosin Vb mutation to exhibit some defects. “We were surprised to find that the intestinal defects in zebrafish were almost identical to humans,” he recalls. For instance, the microvilli, which are essential for absorption of nutrients, were stunted in most cases and even completely absent in extreme cases.

The intestinal folds increase the surface area of the inner intestinal wall.  But the folds were found lacking in fishes that had the myosin Vb mutation; the walls appeared smooth instead. And this is presumably due to changes in the intestinal cell shape and density.

zebrafish embryos

Zebrafish makes it easy to examine the defects in the intestine as embryos are transparent.

The third main feature that causes malabsorption of nutrients is the presence of large vesicular bodies in the intestinal cells called inclusion bodies. The inclusion bodies were found to trap microvilli inside them thereby preventing the microvilli from being exposed on the surface of the intestinal wall.

Though normal and mutant larvae ingested chicken egg yolk, the ability of mutant larvae to absorb lipids was less compared with normal fish, thus testifying the decreased capacity of intestinal cells to absorb nutrients.

The zebrafish disease model has two major advantages over mice disease models for MVID.  First, it is easy to examine the defects in the intestine as embryos and early larvae develop outside the mother and are transparent.  Second, each zebrafish couple produces 100-250 embryos and, hence, enough mutant embryos (quarter of the total progeny) can be obtained for analyses.

Dr. Niranjan Thomas, a specialist in neonatology from Christian Medical College Vellore, who reported an MVID case in India, thinks that the disease probably goes under-diagnosed in India. “This disease is prevalent in Turkish population due to consanguineous marriages. Since such marriages are not uncommon in India, it is surprising that only two cases of MVID have been reported so far,” Dr. Sonawane says. “There is a need to track familial history in Indian population followed by genetic screening for MVID especially when couples lose babies due to chronic diarrhoea soon after birth.”

Published in The Hindu on September 11, 2016

Women live four years longer than men in India

People in India live significantly longer now compared with 1990. Life expectancy increased by 6.9 years for men and 10.3 years for women between 1990 and 2013, notes a study published in the British medical journal The Lancet .

In 1990, the figures were 57.25 for men and 59.19 for women. This rose to 64.16 and 68.48 respectively by 2013.

Healthy life expectancy too is for women. For men, it increased from 50.07 in 1990 to 56.52 in 2013, while for women it rose from 50.15 to 59.11. Ischemic heart disease, chronic obstructive pulmonary disease (COPD), lower respiratory tract infections, tuberculosis and neonatal disorders caused the most health loss.

In 2013, the top 10 causes of disability-adjusted life years in both sexes in India were from ischemic heart disease, COPD, TB, lower respiratory tract infections, neonatal pre-term birth, neonatal encephalopathy, diarrhoea, stroke, road injuries, and low back and neck pain.

For men, the leading causes of health loss between 1990 and 2013 were self-harm, ischemic heart disease and stroke, which increased at rates of 149.9, 79.9 and 59.8 per cent respectively. Self-harm did not figure among India’s top 10 causes in 1990 but was ranked 10th in men in 2013. Iron-deficiency anaemia, ranked ninth in 1990 in men, was no longer a cause by 2013.

For women, the largest increases among leading causes of disability-adjusted life years occurred owing to ischemic heart disease (69 per cent), depressive disorders (66.1 per cent), and stroke (36.8 per cent). Only ischemic heart disease was among the 10 leading causes of health loss for women in 1990. Stroke and depressive disorders were the causes of health loss recorded in 2013 but not in 1990 in Indian women. “More awareness of mental health issues and better detection and documentation could be one of the reasons for depressive disorders to show up in the list,” said Soumya Swaminathan, Director-General of the Indian Council of Medical Research and a co-author of the journal paper.

“The big jump in life expectancy is in keeping with the development of the country,” said Nobhojit Roy, surgeon and public health specialist from BARC Hospital, Mumbai, and a co-author. “But the downside is that diseases that were not seen in 1990 are seen now. India is transitioning and inheriting some of the diseases seen in the developed countries.”

In order to tackle the disease burden better, the ICMR and the Public Health Foundation of India, along with the Ministry of Health and Family Welfare, are planning a disease burden study at the State level. “It will help in better health planning, policy framing and fund allocation,” Dr. Swaminathan said. “We will also look at the risk factors for diseases in the States. This will help each State to know the major diseases and risk factors.”

Published in The Hindu on August 27, 2015

India turns spotlight on adolescent health


Dr. Flavia Bustreo. – Photo: R. Prasad

“India has demonstrated very strong leadership in positioning adolescent health as part of continuum of care. India has taken the lead to present to the rest of the States why it is important to have a discussion on adolescent health,” said Dr. Flavia Bustreo, Assistant Director-General of Family, Women’s and Children’s Health, WHO, Geneva. She was recently in New Delhi to attend the Global Expert Consultation meeting.

Last year, India had requested a discussion on adolescent health at the equity board of the WHO. There were discussions at the equity board this year as well. “We will have a development of framework on adolescent health which will be discussed by all health ministers at the UN General Assembly in May this year,” she added.

In February 2013, at the Summit on the Call to Action for Child Survival, India launched its ambitious new Reproductive, Maternal, Newborn, Child and Adolescent Health strategy, now known as RMNCH+A, to accelerate mortality reduction amongst the country’s most vulnerable women and children.

India has every reason to take the lead — it has a huge adolescent population of 243 million, constituting over 21 per cent of the country’s population. India is yet to meet the Millennium Development Goal 4 (under-5 mortality rate) and MDG 5 (maternal mortality rate).

Overlooking the health of the adolescents has been one of the main reasons why it has failed to reach these goals till now. The adolescent period provides a second chance to improve the health and wellbeing of a child in the second decade of his life.

While what happens during the early years of life impacts adolescents’ health and development, what takes place during the adolescent period affects health during the adult years and even influences the health and wellbeing of the next generation.

Unfortunately, programmes targeted at adolescents are not as advanced as in the case of child health and survival. “We have decades of knowledge, in say, oral rehydration salts (ORS). But in the case of adolescent health, we have only a couple of decades’ knowledge,” she said. “Programmes targeted at adolescents are not so well established. And knowledge and capacity to drive those programmes are not well established.”

Besides health and wellbeing issues like teenage pregnancy, nutrition, alcohol and tobacco consumption, mental health, suicides and road accidents, there are certain interventions which if not applied during the adolescent period can be missed forever. Immunisation of adolescent girls using human papillomavirus (HPV) vaccine can cut deaths from cervical cancer.

As per 2013 data, maternal mortality has been reduced to 2,80,000 across the world. But there are roughly 5,00,000 new cervical cancer cases a year causing nearly 3,00,000 deaths. The HPV vaccine can prevent the onset of cervical cancer if given to girls between 10 and 13 years.

“We are having a discussion on whether the Indian government and society require any other evidence.” Dr. Bustreo said. “But governments have to put in place certain systems.” Since the HPV vaccine serves as primary prevention, governments must also have in place cervical cancer screening, which is secondary prevention. “If you screen and detect cervical cancer, countries should have the ability to treat women, because it is unethical to screen a patient and communicate the news and say we are not able to treat you,” she warned.

Published in The Hindu on March 5, 2015

Editorial: Under-5 mortality – The cost of negligence

The failure of successive governments in India, especially those in States that have the highest mortality rates among children younger than five years, to address the critical issue of training health-care providers in rural areas to correctly diagnose and treat children suffering from diarrhoea and pneumonia, has had tragic consequences. These ailments account for the maximum number of under-5 mortality incidence in the country. That the poor management of sick children by health care providers is a major causal factor for under-5 mortality has been brought out by a study carried out in rural Bihar. As other studies have shown, what is true for Bihar will be largely valid for other States as well. That the 340 health-care providers studied seldom practised what little they knew about treating children suffering from the two health complications is a poignant reminder of the state of the health-care system in rural India. Only 3.5 per cent of the practitioners prescribed the correct treatment using life-saving oral rehydration salts (ORS) alone for children with simple, uncomplicated diarrhoea. Instead, nearly 69 per cent of them prescribed potentially dangerous drugs, including antibiotics, along with ORS; an equal percentage of them prescribed drugs without any ORS. The record was only slightly better in the case of pneumonia. The quality of diagnosis also left much to be desired.

These findings explain why Bihar has the country’s highest infant mortality rate of 55 per 1,000 live births. In 2010, the under-5 mortality in India from diarrhoea and pneumonia was over 600,000, the highest in the world in terms of absolute numbers. In the same year, India was one of the five countries that accounted for nearly 50 per cent of the deaths globally from diarrhoea and pneumonia in this age group. Hence, it is hard to fathom why India did next to nothing to train and equip health-care providers to diagnose and treat children. Bangladesh has not seen any drop in the incidence of acute diarrhoeal disease, but has reduced its under-5 mortality rate by 75 per cent between 1980 and 2011, largely by reducing mortality from the two diseases by means of better case management even in rural areas. In 2006-2007, as much as 76 per cent of children with diarrhoea in rural Bangladesh received ORS, a 2013 paper in The Lancet says. India has indeed done well in reducing under-5 mortality numbers from 2.5 million in 2001 to 1.5 million in 2011. But with only 10 months left to achieve the critical Millennium Development Goal No. 4 of 38 deaths per 1,000 live births among children under five, India can ill-afford to continue with its indifferent attitude to health care in rural areas.

Published in The Hindu on February 23, 2015

The failure of successive governments in Ind

Why rural children in India die of diarrhoea and pneumonia

The reason why a large number of children under the age of five years die of diarrhoea and pneumonia, generally in rural India and especially in Bihar, has become abundantly clear. The results of a study were published a couple of days ago in the journal JAMA Pediatrics.

Diarrhoea and pneumonia are the biggest killer diseases in children aged under five years in India. With 55 per 1,000 live births, Bihar has the highest infant mortality rate in the country. But 340 health-care providers who were studied in rural Bihar rarely practised what little they knew about treating children suffering from these two diseases.

“Vignette” interviews were conducted to assess how they would diagnose and treat children with these diseases. Later, the actual treatment offered by the health-care providers was assessed by sending “patients” pretending to suffer from the same symptoms as in the interviews.

If the providers exhibited “low levels” of knowledge about the two diseases during the interviews, it was even worse during practice. Cheap, life-saving, widely available oral rehydartion salts (ORS) with zinc supplementation is the correct treatment for diarrhoea (2013 WHO recommendation).

During the vignette interviews, a paltry 3.5 per cent of providers offered the correct treatment for diarrhoea. Another 69 per cent offered ORS, but it was in addition to other unnecessary treatments. Some even prescribed antibiotics.

Shockingly, no health care provider prescribed the correct treatment for the “patients” with diarrhoea — only ORS. It was a few shades better in the case of pneumonia where the figure stood at 13 per cent.

Again, if nearly 21 per cent of practitioners prescribed potentially harmful treatment (including antibiotics) without ORS during the interviews, an alarming 72 per cent offered dangerous cocktails that included antibiotics during practice. Antibiotics have no role to play in the treatment of diarrhoea.

In the case of pneumonia, while 12 per cent prescribed antibiotics for pneumonia during interviews, the figure went up marginally to 15 per cent during practice. Severe pneumonia requires treatment with appropriate antibiotics.

“Our ongoing studies aim to understand why providers who know they shouldn’t be prescribing antibiotics for conditions like simple diarrhoea continue to do so,” Dr. Manoj Mohanan from Duke University, North Carolina said in a release.

Besides wrong treatment, the researchers found that the health-care providers asked very few pertinent questions that would enable correct diagnosis and understanding of the severity of the diseases during practice than they did during interviews.

Even the most basic diagnostic question of frequency of stools was asked only by 46 per cent during interviews and 30 per cent during practice. Similarly, in the case of pneumonia, only 27 per cent of the providers asked about rapid breathing and 25 per cent about signs of respiratory distress during practice.

Most distressing was that during practice, 76 per cent of practitioners offered treatment despite not seeing the “sick” child with diarrhoea. It was 79 per cent in the case of pneumonia.

Eighty per cent of the providers in the study did not have a medical degree from any system of medicine — allopathy, ayurveda, homeopathy or unani medicine. While those with formal medical training did have large gaps between what they knew and what they practised, they were “significantly less likely” to prescribe harmful drugs, the study found.

Published in The Hindu on February 17, 2015