Developing training material, getting it approved by the MoH, training trainers & delivering the training is alway an epic feat here. The training for screening & treatment of Severe Acute Malnutrition (SAM) has been no exception. The tribulation has resulted in a heightened state of hysteria which means that I found myself trying to laugh rather than cry.
Having introduced the screening of SAM by showing a video to a group of health workers from four different hospitals we then walked them through the process & practised examples in small group work in the morning. In the afternoon we all went to the hospital to measure the height & weight of some real children. Beforehand there was a short session on common mistakes when measuring children plus any questions for clarification before going to the ward.
It is quite common here for participants to miss the salient points of a training & instead focus on one very, small, irrelevant, uncommon or ridiculous point.
WHO height-weight charts depend on measuring the height of the child & reading what column the weight of the child fits below - this can be one of four results - median, - 1SD, -2SD or -3SD. The charts are for use with children from 6 months to 5 years, the height starts at 52.5cm.
If a child is older than 6 months old but weighs less than 4kg this in itself is a diagnosis of SAM, if a child is 6 months to 5 years & less than 3 standard deviations (SD) they have SAM, if a child is under 6 months with visible wasting they have SAM, and a child of any age has bilateral pitting oedema this is SAM.
These are a sample of the questions the participants focused on during this training;
1) When a child is difficult to weigh you can weigh the child with mother & then just the mother to get the child's weight. The child needs to be weighed without clothes or nappy. SO does the Mother have to take off her clothes also?
It sounds like a saucy joke but this was asked in all seriousness. After a long protracted discussion one of the Cambodian trainers stood up, we thought to clarify that it didn't matter as obviously the mothers weight would be subtracted anyway. This is what he said - "If the Mother has many thick, heavy layers of clothing on you should remove some of them first!" - IN ALL SERIOUSNESS!!!
2) What if a child over 6 months old weighs 3.9kg but by the time they have been transferred to a SAM treatment Hospital they weigh 4.4kg because they have fed?
Again we asked if this has ever happened to anyone - no, but what if?!
We tried to explain that a weight gain of half a kilo in a 3.9kg child was both highly unlikely & more likely to represent a discrepancy in weighing scales than actual weight gain. Participants remained unconvinced. Clearly daily weighing on small children & the patterns of weight gain are unfamiliar to them as they have NEVER done it.
3) What happens if there is a child over 6 months old whose height is less than 52.5cm?
This question clearly demonstrates that they never measure children's height because if they did they would know that the average length on a new born baby is around 50cm & by 6 months of age even the lowest percentile is still way above 52.5cm.
We tried to explain this - they were insistent that this could happen. I asked them for an example of a child they have seen who was older than 6 months, shorter than 52.5cm & heavier than 4kg. They couldn't but they still wouldn't accept the explanation that even if it was possible for a child to be shorter than the lowest height on the chart after 6 month they would almost certainly weigh less than 4kg.
They really couldn't see this. One nurse from my hospital said she had seen a case of a child you was 51cm but sure enough they had also weighed less than 4kg. This still failed to convince the participants.
Jn - my boss - suggested perhaps they were talking about leprechauns. Maybe a human baby had been swapped at birth with a leprechaun, this would make sense. A teeny, tiny leprechaun child that didn't have SAM was just normal size for a leprechaun. Then I suggested that perhaps in fairy land there was an enormous, giant of a human child towering over their leprechaun adopted parents, hysteria kicked in - Jn & I started crying with laughter.
It is estimated that between 50 - 80, 0000 children in Cambodia have SAM but in 2011 only 1226 children were treated for SAM. Cambodian health workers need to stop worrying about impossible clinical anomalies of the WHO height-weight charts & instead concentrate on identifying, treating & saving the lives of the hidden 79,000 Cambodian children who are quite literally starving to death.
Having introduced the screening of SAM by showing a video to a group of health workers from four different hospitals we then walked them through the process & practised examples in small group work in the morning. In the afternoon we all went to the hospital to measure the height & weight of some real children. Beforehand there was a short session on common mistakes when measuring children plus any questions for clarification before going to the ward.
It is quite common here for participants to miss the salient points of a training & instead focus on one very, small, irrelevant, uncommon or ridiculous point.
WHO height-weight charts depend on measuring the height of the child & reading what column the weight of the child fits below - this can be one of four results - median, - 1SD, -2SD or -3SD. The charts are for use with children from 6 months to 5 years, the height starts at 52.5cm.
If a child is older than 6 months old but weighs less than 4kg this in itself is a diagnosis of SAM, if a child is 6 months to 5 years & less than 3 standard deviations (SD) they have SAM, if a child is under 6 months with visible wasting they have SAM, and a child of any age has bilateral pitting oedema this is SAM.
These are a sample of the questions the participants focused on during this training;
1) When a child is difficult to weigh you can weigh the child with mother & then just the mother to get the child's weight. The child needs to be weighed without clothes or nappy. SO does the Mother have to take off her clothes also?
It sounds like a saucy joke but this was asked in all seriousness. After a long protracted discussion one of the Cambodian trainers stood up, we thought to clarify that it didn't matter as obviously the mothers weight would be subtracted anyway. This is what he said - "If the Mother has many thick, heavy layers of clothing on you should remove some of them first!" - IN ALL SERIOUSNESS!!!
2) What if a child over 6 months old weighs 3.9kg but by the time they have been transferred to a SAM treatment Hospital they weigh 4.4kg because they have fed?
Again we asked if this has ever happened to anyone - no, but what if?!
We tried to explain that a weight gain of half a kilo in a 3.9kg child was both highly unlikely & more likely to represent a discrepancy in weighing scales than actual weight gain. Participants remained unconvinced. Clearly daily weighing on small children & the patterns of weight gain are unfamiliar to them as they have NEVER done it.
3) What happens if there is a child over 6 months old whose height is less than 52.5cm?
This question clearly demonstrates that they never measure children's height because if they did they would know that the average length on a new born baby is around 50cm & by 6 months of age even the lowest percentile is still way above 52.5cm.
We tried to explain this - they were insistent that this could happen. I asked them for an example of a child they have seen who was older than 6 months, shorter than 52.5cm & heavier than 4kg. They couldn't but they still wouldn't accept the explanation that even if it was possible for a child to be shorter than the lowest height on the chart after 6 month they would almost certainly weigh less than 4kg.
They really couldn't see this. One nurse from my hospital said she had seen a case of a child you was 51cm but sure enough they had also weighed less than 4kg. This still failed to convince the participants.
Jn - my boss - suggested perhaps they were talking about leprechauns. Maybe a human baby had been swapped at birth with a leprechaun, this would make sense. A teeny, tiny leprechaun child that didn't have SAM was just normal size for a leprechaun. Then I suggested that perhaps in fairy land there was an enormous, giant of a human child towering over their leprechaun adopted parents, hysteria kicked in - Jn & I started crying with laughter.
It is estimated that between 50 - 80, 0000 children in Cambodia have SAM but in 2011 only 1226 children were treated for SAM. Cambodian health workers need to stop worrying about impossible clinical anomalies of the WHO height-weight charts & instead concentrate on identifying, treating & saving the lives of the hidden 79,000 Cambodian children who are quite literally starving to death.
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