EDITORIAL

Advising caregivers

D F Wittenberg

MD, FCP (Paed) (SA). Editor. wittenbergdf@hmpg.co.za

Diarrhoeal disease of infancy will remain one of the major causes of morbidity and mortality in the developing world until the scourges of poverty unhygienic overcrowding and lack of sufficient safe water have been overcome. While this socio-political dimension of disease looms so large, human behaviour is also a major determinant, and caretakers can learn to lessen the risks inherent in an unhealthy environment. One of the major responsibilities of health services is to educate the public about effective preventive healthcare. This extends to learning how to deal with disease and recognising danger signals that necessitate health worker intervention. In the case of acute diarrhoea, the most important learned skill for mothers and caretakers is the application of appropriate oral rehydration therapy (ORT) and early adequate feeding.

This has been known worldwide and adopted as policy for many years, but as Cooke et al.^[1] point out in this issue of SAJCH, has been poorly implemented in many countries. They report on a study of caregiver knowledge and practices around the use of ORT and report a gratifying improvement in its application in their patients compared with a previous study in the same area.

More sobering is the finding, in common with numerous other studies, that most health workers do not give appropriate advice. Only half of first-contact healthcare workers, including general practitioners, advised mothers to give more fluids, while less than 5% gave information regarding danger signs of dehydration. Less than 20% of these health workers advised appropriately on feeding during diarrhoea.

It is interesting to speculate that much apparent caregiver reluctance concerning ORT may actually originate in health worker attitudes and misconceptions. While numerous best-practice guidelines for the management of diarrhoea exist, it is known that diarrhoea guidelines are more frequently ignored by doctors than guidelines for other common conditions such as asthma;^[2,3] it is thought that the reasons lie in doctors' unwillingness to be imposed upon for such a common disease, that the guidelines are considered 'too simple, or that there is parental expectation of drug treatment to stop diarrhoea.

Obviously ORT is not medical therapy and does not treat the symptom of diarrhoea, but in its simplest form is application of the centuries-old practice of replacing body fluids that are lost in diarrhoea stools with an appropriate liquid given by mouth to maintain or restore hydration. When mothers can be helped to understand this and be supported in appropriate early re-feeding, including continued and increased breastfeeding, they become empowered to deal effectively with the majority of cases of diarrhoea in their children.

Communication and informed behaviour change are similarly vital in another condition of huge public health importance. An epidemic increase in the prevalence of childhood obesity is gripping the developing world. This has multiple complex interacting causes including adolescent eating behaviours, as pointed out by Onyiurika et al.^[4] in this issue. For community-wide prevention of obesity, health workers need to understand and promote the totality of a healthy lifestyle rather than emphasising individual behaviour patterns.

Among the other varied offerings in this issue, Springer et al.^[5] report on a series of children with autism spectrum disorder. It is important to note that many children with autism suffer from serious co-morbidities such as cognitive delay, language impairment or problematic behaviour. The condition is probably still significantly under-diagnosed.

In their audit of babies with asphyxia, Padayachee and Ballot^[6] found that the death rate was more than doubled if babies had been born outside and transferred to the referral hospital. We should ask whether the rate of cerebral palsy was similarly increased among the outborn babies who survived versus inborn babies, raising yet another reason why improvements in primary perinatal care are so badly needed.

The term palliative care has most frequently been used in the context of terminal cancer, but it can be applied to management of patients with progressive incurable conditions in many other contexts. In their study of telling bad news, Campbell and Amin^[7] point out cultural complexities around the care and counselling of patients with terminal diseases and their families. Clearly much more research is needed in this ever-widening field.

1. Cooke ML, Nel E, Cotton MF. Pre-hospital management and risk factors in children with acute diarrhoea admitted to a short-stay ward in an urban South African hospital with a high HIV burden. South African Journal of Child Health 2013;7(3):84-87. [http://dx.doi.org/10.7196/SAJCH.472]        [ Links ]

2. Hoekstra JH. Acute gastroenteritis in industrialized countries: Compliance with guidelines for treatment. J Pediatr Gastroenterol Nutr 2001;33:S31-S35. [http://dx.doi.org/10.1097/00005176-200110002-00006]        [ Links ]

3. Migowa AN, Gatim B, Nduati R. Adherence to oral rehydration therapy among inpatient children aged 1 - 59 months with some or no dehydration. J Trop Pediatr 2010;56(2):103-107.         [ Links ]

4. Onyiurika AN, Umoru DD, Ibeawuchi AN. Weight status and eating habits of adolescent Nigerian urban secondary school girls. South African Journal of Child Health 2013;7(3):108-112. [http://dx.doi.org/10.7196/SAJCH.529]        [ Links ]

5. Springer PE, van Toorn R, Laughton B, Kidd M. Characteristics of children with pervasive developmental disorders attending a developmental clinic in the Western Cape Province, South Africa. South African Journal of Child Health 2013;7(3):95-99. [http://dx.doi.org/10.7196/SAJCH.530]        [ Links ]

6. Padayachee N, Ballot DE. Outcomes of neonates with perinatal asphyxia at a tertiary academic hospital in Johannesburg, S outh Africa. S outh African Journal of Child Health 2013;7(3):89-94. [http://dx.doi.org/10.7196/SAJCH.574]        [ Links ]

7. Campbell LM, Amin N. Dilemmas of telling bad news: Paediatric palliative care providers' experiences in rural KwaZulu-Natal, South Africa. South African Journal of Child Health 2013;7(3):113-116. [http://dx.doi.org/10.7196/ SAJCH.590]        [ Links ]