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

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

Preterm births and pneumonia kill most children under five years in India


Pneumonia - Wikimedia Commons

Pneumonia caused 0.14 million deaths in neonates. 

Of the 6.3 million deaths in children under the age of five years, nearly 44 per cent of deaths during 2000-2013 occurred during the neonatal period (0-27 days after birth). Preterm birth complications, pneumonia and intrapartum-related complications have been found to be the three main causes of death in children globally.

The results are published today (October 1) in the journal The Lancet. According to Li Liu from the Institute of International Programs and the first author of the paper, there will be 4.4 million deaths in children younger than five years even in 2030 if the present trend continues.

In 2013, India, Nigeria, Pakistan, the Democratic Republic of Congo and China together accounted for half of deaths in the world in children aged under five years, and 52.5 per cent of all neonatal deaths. In the case of India and Pakistan, the three leading causes were preterm birth complications, pneumonia and intrapartum-related complications, in that order. In the case of China, the order was different — intrapartum-related complications, preterm births complications and pneumonia were the three leading causes.

Globally, preterm birth complications caused 15 per cent (0.96 million) of child deaths in 2013. This was closely followed by pneumonia. While pneumonia caused only 0.14 million deaths in neonates, at 0.8 million, it was the second major cause of death across the world in children aged 1-59 months. The two periods together accounted for 0.93 million deaths caused by pneumonia in children aged under five years. As expected, diarrhoea killed more children after the neonatal period — 0.02 million during the neonatal period and nearly 0.59 million during the period 1-59 months.

Case management of pneumonia and diarrhoea can be easily implemented and large number of deaths can be prevented with minimum intervention at little cost. Use of antibiotics to treat pneumonia and timely oral rehydration therapy in the case of diarrhoea can prevent deaths in children under five years.

“Deaths due to pneumonia and diarrhoea can be reduced in India. The coverage [of antibiotics and oral rehydration therapy] is not wide enough in India … it’s not sufficient,” Prof. Robert E. Black from the Johns Hopkins Bloomberg School of Public Health and the Corresponding author of the paper told this Correspondent. “Pneumonia [occurs] during and after neonatal period and diarrhoea [occurs] mainly after neonatal period.”

For pneumonia less than 30 per cent of children in India receive antibiotics, and over 600 million defecate in the open and have very poor access to clean drinking water resulting in most cases of diarrhoea.

“Compared to managing premature babies which involves sometimes months of intensive care, complex medical treatments and follow-ups, treatment for pneumonia (early diagnosis and three-day antibiotic treatment costing about Rs.25) and diarrhoea (oral rehydration therapy) are relatively straight forward and will save a lot more lives in the short term,” Dr Nicholas Furtado Attending Paediatrician, University of Illinois Hospital and Health Sciences System, Chicago said in an email to this Correspondent. Dr. Furtado was not involved in the study.

“In the long term, prevention of pneumonia by immunisation, acute diarrhoea by improving water supply and sanitation, and decreasing prematurity through quality care before, during and after birth would be the most important ways to decreased under five mortality rate,” Dr. Furtado noted.

Explaining why pneumonia cases are more common than diarrhoea, Dr. Furtado said: “During the neonatal period the lungs are immature and more prone to infection.”

Simple measures like exclusive breastfeeding for six months can further cut the number of diarrhoeal episodes and deaths in children. However, only about 46 per cent of children in India were exclusively breastfed for six months during 2005-2006.

It is to be noted that reduction in pneumonia, diarrhoea and measles during the period 2000-2013 has led to nearly 50 per cent decrease in deaths in children under five years.

Preterm births

India is one of the 10 countries with an estimated 100,000 to 250,000 preterm births in 2010. Preterm births cause about 50 per cent of neonatal mortality. “The causes of preterm births are not known. Conditions like high blood pressure in pregnant mothers and infections during pregnancy are some of the reasons. In a majority of cases no cause can be attributed. It’s hard to prevent preterm births,” said Prof. Black.

“Preterm birth complications will probably remain the leading cause of neonatal and under five deaths,” the paper notes.

But measures like supported infections control, kangaroo care (skin to skin contact of the baby with the mother to keep the baby warm) and use of incubators will go a long way in preventing deaths even when the baby is preterm. “We can’t prevent preterm births but can treat them and prevent most of the deaths,” Prof. Black said.

“In this analysis we didn’t include small for [gestational] age as a risk factor,” he said. Most small-for-gestational-age infants are born in India, Pakistan, Nigeria, and Bangladesh.

A July 2013 Comment piece in The Lancet notes: “In 2010, an estimated 32·4 million infants were born [at term but] small for gestational age in low- and middle-income countries (27 per cent of live births).”

Published in The Hindu on October 1, 2014

Editorial: Clean hands, stay healthy

Published in The Hindu on May 21, 2012

India is once again in the news for all the wrong reasons. Along with four other countries India in 2010 accounted for half the estimated number of global deaths from eight main causes in children younger than five years. A recent study in The Lancet has revealed that half the number of global deaths caused by infections again took place in these five countries. In all, there were nearly 1.7 million estimated deaths in India that year. With nearly 400,000 deaths, pneumonia turned out to be the top killer disease, followed by diarrhoea causing more than 210,000 deaths. In fact, India is one of the five countries where most have died from two preventable infectious diseases — pneumonia and diarrhoea. Apparently, in India, pneumonia felled the most in both age groups — about 143,000 deaths in neonates (less than 28 days old) and nearly 254,000 in those aged 1-59 months. The corresponding mortality figures for diarrhoea were nearly 19,000 in neonates and 193,000 children aged 1-59 months. That no significant improvements took place during the period 2005-2010 became clear in a November 2010 The Lancet study that looked at the estimated deaths in 2005 at ages 1-59 months. Half the 1.5 million deaths in 2005 were from pneumonia and diarrhoea.

These findings should come as no surprise as the main causative factors have yet to be addressed. A majority of people, especially in rural areas, do not have access to safe drinking water, and sanitation and hygiene levels are terrible. A recent UNICEF report says 638 million people, or nearly 54 per cent of the population, defecate in the open. The corresponding figure in Bangladesh and Brazil is just seven per cent. The report adds that only six per cent of rural children below five years used toilets. While Jairam Ramesh, Union Minister for Drinking Water and Sanitation, is determined to rid the country of open defecation by 2017, what needs to be undertaken immediately is to spread a simple yet cost-effective public health message — the importance of handwashing with soap after defecation. Unfortunately, only about half of all Indians regularly wash their hands with soap after contact with excreta. Washing hands can cut diarrhoea by over 40 per cent, and about 30 per cent of respiratory infections, including pneumonia, can be avoided. The gain is more if this practice is adopted before eating. Global Handwashing Day, endorsed by many countries, including India, was initiated in 2008 to drive home this important message. But awareness building should be a continuous process and cannot be restricted to just one day.

‘There is an absence of political will to give primacy to health’


About 73 per cent of public hospital bed are located in the urban areas though 69 per cent of India’s population lives in rural areas.

India has to not only increase resources for healthcare but also radically transform the architecture of the country’s healthcare delivery system, if the nation is to achieve the government’s vision of assuring health for all, says a paper published in The Lancet on Friday. There are several deficiencies and structural problems with the health-care system that fails to assure health coverage for all in India.

“No government has treated healthcare with the same attention as education,” Prof. Vikram Patel, the lead of the paper from the Delhi-based Public Health Foundation of India told The Hindu. “There is no ownership of health as a national public good by the medical sector, the government or the civil society.”

“Treating health as a private commodity without adequate checks and balances would result in irrational practices leading to impoverishment,” said Prof. Patel. “Health seen as a private commodity is not consistent with universal health goal.”

It is a fact that a large proportion of the population stands impoverished as a result of high out-of-pocket health-care expenditures and people also suffer the adverse consequences of poor quality of care.

Even today, widespread inequities in health outcomes are seen between and within States, urban and rural population, rich and poor, boys and girls. For instance, infant mortality rates in rural and urban areas differ by 17 points. Nearly 25 per cent of children born to the poorest people are severely malnourished compared with 5 per cent children born to the richest people. A girl born in Madhya Pradesh or Chhattisgarh is five times more likely to die before turning one year compared with a girl born in Kerala. In 2012-13, with varying infant mortality rate even with Assam, a child born in Kokrajhar district in Assam had greater chances of dying than a child born in Dhemaji district.

Despite higher income per head and sustained economic growth for over two decades and substantial improvements in some health indicators in the last decade, India continues to fare badly on many health indicators compared with other middle-income countries and its neighbours like Nepal and Bangladesh.

For instance, India accounted for 20 per cent of the global burden of disease in 2013, as against 21 per cent in 2005. Nearly 27 per cent of all the neonatal deaths and 21 per cent of all deaths in children younger than five years take place in India. Diarrhoea, pneumonia, preterm birth complications, birth asphyxia, and neonatal sepsis are responsible for 68 per cent of all deaths in children of this age group. About 39 per cent of the children in this age group suffer stunting. More than 6 per cent of women are severely undernourished — which is among the highest in low-income and middle-income countries.

India faces a double whammy of communicable and non-communicable diseases. Non-communicable diseases are responsible for 52 per cent of all disease burden and more than 60 per cent of deaths in the country. Nearly 65 per cent of Indians have diabetes. On an average, Indians get their first heart attack when they are 50 years old, at least 10 years earlier than in developed countries.

While ischaemic heart disease, chronic obstructive pulmonary disease, depression, stroke, diabetes, and low back pain were among the leading non-communicable causes disease burden 2013, TB, lower respiratory infections, diarrhoeal diseases, malaria, and typhoid count among the communicable diseases.

According to the authors, the health-care system in India faces seven key challenges — a weak primary health-care sector, unequal distribution of skilled human resources between private and public sectors, unregulated private sector, low public spending on health, irrational and spiralling cost of drugs and technology, weak governance and accountability, and fragmented health information systems.

Primary health-care sector

Though primary health-care infrastructure improved between 2005 and 2015, the expansion in public services has been “inequitably distributed.” “The primary health care is weakening in all States; it is consistently falling. The gravest concern is that the private sector is taking its place,” said Prof. Patel. “The migration of patients to the private sector has still not been stopped.”

About 73 per cent of the public hospital beds are located in the urban areas despite 69 per cent of India’s population residing in rural areas. “There continues to be an overall availability shortfall of 22 per cent of primary health centres, and 32 per cent of community health centres that serve people living in rural areas across the country,” the paper notes. The shortfall in health facilities is felt the most in States like Bihar and Madhya Pradesh.

There is inequitable expansion of public services across India with some States being better off than others. For instance, Goa has one bed per 614 persons while it is one bed for 8,789 persons in Bihar.

Even the quality of care offered in PHCs is uneven and poor. “By the end of March 2015, only 21 per cent of primary health centres and 26 per cent of the community health centres were functioning as per Indian Public Health Standards set by the Health Ministry,” the paper notes. Even the functionality of PHC services is limited by high absenteeism, distant locations and inconvenient timings.

According to the results of the National Sample Surveys on social consumption, there has been a “steady decrease” in the use of public hospitalisation services in the last two decades. The decrease was greater in the urban areas (from 43 per cent in 1995-96 to 32 per cent in 2014) than in rural areas. Use of public services also decreased sharply by the rich both in urban and rural areas.

Skilled human resources

“India does not have an overarching national policy for human resources for health,” notes the paper. Last year only 11.3 per cent of allopathic doctors worked in public sector. Of this, only 3.3 per cent worked in rural areas.

“Community health centres in rural areas of the Indian states of Haryana, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, West Bengal, Gujarat, and Himachal Pradesh, North Eastern States and Jharkhand face shortfalls of specialists exceeding 80 per cent,” the paper highlights.

Unregulated private sector

The private sector has grown and filled the vacuum created by the public sector, which has been unable to expand and meet the demand of the population, both in rural and urban areas. The worrying part is that the private sector is “mostly unregulated.”

“In 2014, more than 70 per cent of outpatient care (72 per cent in the rural areas and 79 per cent in the urban areas) and more than 60 per cent of inpatient care (58 per cent in rural areas and 68 per cent in urban areas) was in the private sector,” the paper notes. The growth has been so much so that between 2002 and 2010, about 70 per cent of increase in hospital beds was met by the private sector.

As a result of the skewed availability of services from the private sector, private practitioners have become the first point of contact for a vast majority of people in India. While the private sector has managed to reach and spread across the country, they have not been able to ensure quality. “Substantial proportion” and in some cases the “majority” of doctors in the private sector are either “unqualified or underqualified.” In rural Madhya Pradesh, only 11 per cent of the health-care providers had a medical degree.

“Informal care providers, with no formal medical training or registration with government for medical practice, are estimated to represent 55 per cent of all providers and are also frequently the first point of contact, especially in rural areas,” the paper notes.

“With few exceptions, the quality of care in the organised private sector also remains suspect,” it warns.

Low public spending on health

The public health expenditure as a proportion of GDP remains at just 1.28 per cent of the country’s GDP in 2013-2014. “The government has to spend more, and more importantly it has to find more imaginative ways of spending the money,” said Prof. Patel.

Although there was plan to increase by 34 per cent every year the Central government’s assistance to State governments for their annual plans in the 12th five year plan, in reality the increase was less than 1 per cent between 2008-2009 and 2012-2013. At the same time, the State government’s expenditure on health shot by 7 per cent. “As a result, the central government’s share in public health expenditure has remained less than 30 per cent since 2010 and has reduced progressively, even if marginally,” it notes.

With States lacking the absorptive capacities and also not spending the allotted money, the actual money released by the Central government to respective States is even less.

The low expenditure by the public sector has in turn led to an increase in out-of-pocket expenditure by the people. “In 2013, out-of-pocket expenditure accounted for about 58 per cent of the total health expenditure on health in the country,” the paper highlights. As a result, in 2011-2012, 55 millions were estimated to have fallen into poverty due to health-care costs.

Several insurance covers provided by the government have helped mitigate the problem. By 2010, close to 25 per cent of the populations has some level of financial protection. But that still leaves a majority without cover.

Spiraling cost of drugs

India spends a meagre 0.1 per cent of GDP on publicly funded drugs, notes the paper. As a result about two-thirds of the total out-of-pocket expenditure is for drugs. The government’s plan to provide 361 generic drugs at affordable cost through government-run pharmacies was to be launched in 2008. By 2012, of the 600 pharmacies that were supposed to be established, only 170 were opened in select States. Of the 170, only 99 were functional in October 2014.

“Tamil Nadu has a central drug procurement system in place and it works excellently,” said Prof. Patel. Rajasthan too has implemented the provision of free essential medicines in the public system.

The paper outlines a three point action plan to both combat and counter these constraints and weaknesses facing India’s health sector. First, there is low public spending on health and “stagnation” in public spending in the past decade. “There is an absence of political will to give primacy to health in India’s development agenda and a belief that economic growth by itself will lead to sufficient health gains,” the paper notes. Second, trust and engagement between various health care sectors is simply missing. Third, the health care sector is fragmented with poor coordination between central and state governments.

“At the heart of these constraints is the apparent unwillingness on the part of the state to prioritise health as a fundamental public good, central to India’s developmental aspirations, on par with education,” the authors write.