TM5559: Clinical Tropical Paediatrics

Case Study Three: A case of malaria and malnutrition in pregnancy Samantha Leggett: SN 12494652

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Case Study Three

A case of malaria and malnutrition in pregnancy.

Name: AA

Age: thinks 37 but doesn’t know year of birth. No details noted in health record.

Sociodemographic details

Home: Uia Village, Bugati, Madang (1 ½ hrs (4 kina) on the PMV)

Religion: Christian Revival

Clan: Unknown

Age married: doesn’t know but was pregnant for the first time when she got married so approximately 11 ½ years ago at 25 years of age

Husband’s age: Similar according to AA

Education: None

Employment: AA’s family have a market garden

Alcohol, tobacco and betel nut use: AA stopped chewing betel nut when she joined the church and she doesn’t drink or smoke. Her husband chews regularly, drinks alcohol and has given up smoking tobacco.

Maternal Parents: Alive and well, no health problems known

Number of Children: Seven babies in eleven years; the first 5 born at home, the last two in hospital. AA reports no deaths and all children healthy and vaccinated at their local clinic. The eldest two children are at school.

Background

In June 2010 AA presented to Danben clinic (her local community health centre) reporting three months of amenorrhoea and a recent history of three days of vaginal (PV) bleeding. Her health record indicates that she was diagnosed with a complete spontaneous abortion.

AA then re-presented to Danben clinic in August 2010 saying that she hadn’t menstruated for two months (NB since June PV bleed). She

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was diagnosed as pregnant at this point and her weight is noted as 43kg. In mid-September her heath record notes that the fundal height was 30cm and AA’s weight is still 43kg. Four weeks later in mid-October fundal height was 31cm and AA’s weight remained at 43kg.

This pregnancy AA’s health record notes that she appears pale, thin and wasted and documentation indicates that she was continuously ill with loose watery diarrhoea. There is no indication of any malaria testing or any treatment-preventive or curative.

AA’s health record also documents that she was treated for severe malaria in her previous pregnancy and was anaemic with haemoglobin (Hb) of 9.1. She is also noted still to be breast feeding her previous child.

During her antenatal visits to Danben clinic this pregnancy AA was educated regarding danger signs in pregnancy and advised to travel to Modilon General Hospital (MGH) if she recognised any of them as she was considered a high risk pregnancy. Very soon after her second ante natal visit AA went into labour.

Medical History

AA was admitted to MGH on the 15/10/10 with a history of eight hours of labour pains. Her hospital notes indicate that she “looks ill but isn’t talking”. The baby was assessed to be a normal presentation, the foetal heart rate was satisfactory and membranes were intact (it is documented that when they ruptured the liquor was “brownish-like old blood”). Baby was born by standard vaginal delivery at 7.37pm in good condition with an APGAR of 7 at 1 minute and immediately self ventilated in low flow oxygen. No further respiratory support is documented in baby’s notes. She weighed just 1000g and was diagnosed as being severely premature with intrauterine growth restriction (IUGR). Shortly after birth baby was also diagnosed as anaemic with a Hb of 11.8g/dl.

My Assessment

I spoke with AA on a number of occasions during my visits to the special care nursery and was very sensitive to the fact that she was also being interviewed by a number of other students. My main interview was for the purpose of sociodemographic data gathering and confirming information given in the community health record. On other occasions when the unit was quiet I attempted to make conversation with AA but she seemed very shy and reluctant to talk. She did tell me that she had been very unwell during her pregnancy but was “feeling ok again now that the baby was out”. She also offered that she was finding it very hard to find money to pay for her children’s schooling while she was in hospital with the baby and that her Mother was tending the market garden. She expressed a very strong desire to leave the hospital and return home to the rest of her family.

Diagnosis

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Chronic malnutrition, repeated malarial infection and anaemia compounded by substandard antenatal care leading to the delivery of a premature and IUGR infant.

Figure 1. AA and her baby in MGH special care nursery

Malnutrition, infection, anaemia and pregnancy

Maternal morbidity and mortality is a major public health issue in developing countries with maternal mortality rates (MMR) 50-100 times higher than those in developed countries [1,2]. Malnutrition, anaemia from one or more causes and malarial disease all contribute significantly to this MMR and subsequently increase a woman’s risk of delivering a low birth weight infant [3] which we know is an important cause of infant and child mortality and morbidity [4,5].

For the purpose of Clinical Tropical Paediatrics the focus of this assignment will be the consequence of these diseases during pregnancy for the developing foetus, the child and adolescent and how interventions targeted at antenatal services can help to prevent them. The terms malnutrition and undernutrition will be used interchangeably and for the purposes of this paper indicate the same condition.

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Malnutrition

Undernutrition is the result of an inadequate dietary intake of micronutrients and energy either resulting from poor quality food, or not enough food [6]. In resource poor countries a cycle of malnutrition, infection and poverty exists. It has been observed that gender bias predisposes the female child to a poor nutritional status which continues through adolescence, leading to a negative nutritional balance as the woman enters her reproductive years. Nutritional status then further deteriorates due to the burden that pregnancy places upon the body, putting the woman at greater risk of acquiring an infection and also delivering a malnourished or premature infant. The cycle of malnutrition and thus poverty then perpetuates into the next generation: low birth weight infants are at risk of poor growth and development throughout childhood and this leads to malnutrition in adolescence. The female child once again enters her reproductive years in a malnourished state placing her at risk of giving birth to a premature or low birth weight infant [3,7]. Undernutrition contributes to greater than one in three child deaths worldwide [6] and Table 1 below demonstrates the deleterious effects of maternal micronutrient deficiency upon the child [8].

MICRONUTRIENT DEFICIENCY

CONSEQUENCE

Calcium Rickets

Folic acid Neural tube (e.g. spina bifida) and other birth defects

Iodine Impairment of motor and mental development of the foetus, increases risk of miscarriage, increased risk of foetal growth restriction, goitre, congenital hypothyroidism and developmental disability

Iron Iron deficiency anaemia

Vitamin A Impaired immunity and production of RBC’s and platelets in bone marrow. Night blindness; xerophthalmia. Growth retardation.

Vitamin B12 Possibly neural tube defects and early foetal loss. Failure to thrive, stunting, poor neurocognitive function, global developmental delay

Vitamin D Deficiency in utero can cause poor foetal growth and skeletal mineralisation leading to rickets and poor bone mineralisation in the first years of life.

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Zinc Stunting, increased risk of diarrhoea, pneumonia and malaria and subsequently an increased risk of stunting

Table 1: Maternal micronutrient deficiencies and their consequences for children

The intertwined and cyclical relationship of malnutrition and infection and its outcomes further demonstrates that malnutrition is one of the most serious and enduring health problems of developing countries [3,9]: Several micronutrients have immunomodulating and antioxidant functions; Malnutrition and thus a micronutrient deficiency will therefore negatively affect the susceptibility of the individual to infection (e.g. malaria) and to the course and outcome of the disease [10]. The malnourished body provides the perfect environment for the establishment, survival and proliferation of infection [11]. Although these important interactions aren’t specific to pregnancy, the increased demands upon micronutrients during pregnancy exacerbate the deficiency and its consequences [3].

Malaria

Malaria is a parasitic disease transmitted by the bite of an infective female Anopheles mosquito. In 2008 there were in the region of 247 million cases of malaria in the world and around one million deaths as a result. At any time over half of the world’s population in poor tropical and sub-tropical countries are at risk of contracting malaria [12,13].

Humans are the main reservoir of the four human malarial parasites-Plasmodium falciparum and P. vivax being the most common and then P. ovale and P. malariae. The feeding hours of the malaria vector are between the hours of dusk and dawn with varying Anopheles species having different feeding times during this period. Transmission is also possible via an injection or transfusion of infected blood, or through the use of contaminated needles or syringes (for example amongst drug users) [14]. Congenital malaria can also occur [15].

With regards to communicability, humans can infect mosquitoes for as long as infective gametocytes (the sexual stages of the parasite) are present in the circulating blood. Untreated or insufficiently treated humans can be a source of infection for between one and five years depending on the Plasmodium species. Once infected, the mosquito remains infective for life but needs to be alive for at least one week for the development of the parasite to be complete [14].

In areas of endemicity some level of immunity to malarial disease is demonstrated in adults who have been continually exposed to infective anophelines over a number of years. Immunity will never offer complete protection from malaria but protects against the most severe manifestations of the disease. This immunity is lost if adults move away from a malaria endemic area. Their risk

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of contracting malaria upon re-entering an endemic area would be the same as that of an unexposed individual [12,14]. Certain genetic traits and the presence of HIV present various modes of protection and risk but will not be discussed here.

Pregnant women are particularly vulnerable to malaria as pregnancy lowers a woman’s immunity to malaria making her more susceptible to infection and at higher risk of adverse disease outcomes and severe anaemia [16]. P. falciparum appears to be the specific culprit with research demonstrating that this malaria species is the only human parasite with a clear and substantive adverse effect on pregnancy, nutrition during pregnancy and pregnancy outcome [3]. Semi-immune pregnant women in areas of high transmission (such as AA in Madang) are particularly at risk of adverse effects for the developing foetus such as spontaneous abortion, stillbirth, premature delivery and delivering a low birth weight infant-a leading cause of child mortality [16,17]]. Landis et al [18] demonstrate a detrimental effect of both recent and cumulative malaria infection on the risk of delivering a low birth weight infant. This risk was strongest in undernourished women. Women with a normal BMI who also had malaria didn’t have adverse foetal outcomes.

Malaria eradication is a significant public health issue and vector control is the primary method of achieving a reduction in transmission at a community level [12]. A number of measures are advocated in the literature and WHO (16) promote a three pronged approach to malaria prevention in pregnancy. Two will be discussed here: insecticide treated mosquito nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp).

Insecticide treated mosquito nets (ITN) are the most universally effective measure of preventing malaria [14]. Their use has an impact upon maternal anaemia and can significantly reduce the incidence of low birth weight in infants [19]. Malaria carrying mosquitoes bite between the hours of dusk and dawn and sleeping under a mosquito net therefore provides a physical barrier between host and vector. If the net is treated with an insecticide the barrier extends beyond the net, effectively creating a halo of protection. This deters the mosquito from biting or shortens its life span so the malarial parasite does not have time to reproduce [20]. High levels of bed net usage within a community are likely to afford protection to individuals who don’t use nets as well as to those who do [13]. Young children and pregnant women are the immediate priority while ITN distribution programmes are being established.

Papua New Guinea (PNG) has an estimated 1.5 million cases of malaria resulting in around 3000 deaths annually. Outside of sub-Saharan Africa, Papua New Guinea is the only other country in the world with an estimated incidence of malaria >200/1000 of the population [13]. Malaria is highly endemic and predictably stable in coastal regions but less stable in the highlands where epidemics with large fatality burdens occur. 70-80% of infections are due to P. falciparum and the remainder to P. vivax. More than 94% of the population live in high transmission areas. At the current time malaria is one of the two leading diseases in PNG [21].

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Papua New Guinea began its public health programme of distributing free ITN’s in 2004 and by 2008 had achieved 24% coverage of all people at risk of malaria with ITN’s significantly targeting the most vulnerable members of the population as per WHO recommendations; one of only ten countries in the world to have achieved coverage of >10% of the at risk population. It is noted however that antenatal clinics are not being used as a hub for distribution. Rotarians against Malaria [22] have a large and ambitious programme in PNG and are aiming to halve mortality due to malaria in the next five years. Their goal was to distribute 1 million bed nets in 2010 and they aim to do the same in 2011 however no data is available on their website to confirm whether their targets have been met to date. Data also indicates that the Western Pacific region receives the lowest amount of funding for malaria control programmes in the world [13]. In 2007-2008 malaria still accounted for 250 outpatient visits per 1000 population in PNG [21].

The Papua New Guinea Institute of Medical Research (PNG IMR) has an important and ongoing study relating to ITN distribution. Interestingly they have discovered that the differing species of anopheles appear to be able to adapt to the introduction of ITN’s by changing their peak biting times. For example Anopheles farauti had a peak biting time of 11-12pm before the introduction of ITN’s. Similarly A. punctualis had a peak biting time of 1am. After the introduction of ITN’s the peak biting time of A. farauti changed to 8-9pm and A. punctualis to 10-11pm. A shift in vector composition has also been noted and the IMR warn that this evidence may have the potential to compromise bed net distribution programmes (pers. comm. Lisa Reimer PNG IMR).

Intermittent preventive treatment in pregnancy (IPTp) has also been shown to be a highly effective measure for reducing the burden of malaria among pregnant women and their neonates [23-25]. Menendez et al [23] demonstrate a 61% reduction in neonatal mortality, reduced risk of placental parasitaemia, reduced risk of LBW and an increase in maternal Hb through the correct use of IPTp. Gies et al [24] warn that the most beneficial effects on LBW are seen in primigravidae and that this must have an impact on programme planning. WHO [13] advocate that in areas of high transmission ITP with sulfadoxine-pyrimethamine (SP) should be administered to all pregnant women at least twice during the second and third trimesters of pregnancy (and three times in the case of HIV positive women). To 2008 Papua New Guinea had not adopted any IPT programmes for pregnant women [13] with bi-monthly chloroquine prophylaxis in pregnancy being advocated in local guidelines [26]. Tiono et al [25]demonstrate that IPTp with SP is a far superior method of malaria prevention than weekly chloroquine prophylaxis, particularly given the resistance trends of P. falciparum. Menendez et al [27] believe that proper and consistent use of ITN’s during pregnancy may reduce the need to administer IPTp.

In Papua New Guinea 76% of women attend antenatal clinic at least once during pregnancy [2,28] presenting a major opportunity to prevent and treat malaria [16]. Although, it is important to note that 16% of women still receive no antenatal care at all. WHO [16] recommend that malaria prevention and treatment is integrated into existing antenatal care (ANC) services

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making the programme a standard and integral component of ANC. Papua New Guinea’s main health concern is poor maternal health [21] and the neonatal mortality rate (deaths of neonates often being as a result of poor maternal health) is little changed since 2000.

The Manual of Standard Managements in Obstetrics and Gynaecology in Papua New Guinea [26] advocates that malaria prevention should be a major priority within the antenatal clinic, particularly in areas of high transmission. It is advised that “all pregnant women should be encouraged to obtain a treated bed net and sleep under it every night. All ANC’s should try and become distributors of treated bed nets” [p91]. Further it is prescribed that in areas with year round malaria transmission (e.g. Madang) pregnant women should receive a treatment course of anti-malarials on booking (Chloroquine 3 tablets daily for 3/7 and Fansidar 3 tablets stat dose) and then weekly Chloroquine prophylaxis throughout pregnancy. This is not in line with current WHO recommendations [13].

The economic impact of malaria is also an important consideration. In some heavy burden countries the disease accounts for up to 40% of public health expenditure, 30-50% of inpatient hospital admissions and up to 60% of outpatient health clinic visits. Malaria disproportionately affects the poor who often have limited access to health care, trapping families and communities in a downward spiral of poverty [12].

Anaemia

Anaemia in pregnancy constitutes a major public health problem in developing countries affecting half of all pregnant women [29,30] and is multifactorial in aetiology [31]. The more severe the anaemia the more likely it is to have multiple causes. Nutritional deficiency is a major component of severe anaemia even in malarial areas and in malaria endemic areas anaemia is one of the commonest preventable causes of death in children under five and pregnant women [30]. Additionally it has been demonstrated that foetal growth is compromised in maternal anaemia [29,31].

Research indicates a high prevalence of anaemia in pregnant women in the Madang region of Papua New Guinea. 44% of primigravidae and 29% of multigravidae had severe anaemia (Hb<8g/dl) after 28 weeks gestation-anaemia was shown to be worse in the presence of iron deficiency. The study also found that a positive malaria screen at booking and a negative screen at delivery translated to a higher Hb at delivery than at booking. Allen et al [32] found a decreased maternal Hb concentration to be the main determinant of pre-term birth. These findings have important implications for the effectiveness of malaria prevention programmes in controlling maternal anaemia [31]. Additionally, public health programmes that target nutrition and helminth and malaria control have been shown to impact on anaemia prevalence [30].

The Manual of Standard Managements in Obstetrics and Gynaecology in Papua New Guinea [26] cites that anaemia is the most common medical problem related to pregnancy in PNG.

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Anaemia prophylaxis of iron and folate plus standard treatment of malaria is advised for all pregnant women. For women who appear clinically anaemic (i.e. mucous membranes, palms of hands, conjunctivae and nail beds) on booking a treatment course of iron and folate in addition to anti-Helminthics is prescribed. AA’s health record documents that she ‘appears pale, thin and wasted’ but no interventions are documented.

Maternal education, working practices and birth weight

Briefly because it is also of significance, this baby is baby number seven in eleven years for AA. Adequate birth spacing creates better survival odds for children in developing countries. An infant born less than two years after a sibling is 85% more likely to die in their first year of life than if the interval had been three years or more. Infant mortality is also influenced by family size; children who are born fourth or lower in birth order are over 50% more likely to die in infancy [21]. Further, multiple pregnancies increase the amount of nutrients that have to be delivered over the course of a single pregnancy. A shorter inter-pregnancy interval limits the opportunity for the repletion of nutritional reserves between successive pregnancies. All of these factors have been shown to impair the opportunity for the foetus to grow and develop normally [33]. At the current time only 24% of married women are using modern methods of contraception [28] representing a further missed opportunity to improve maternal and child health and reduce mortality.

Muthayya et al [34] demonstrate a low maternal education level as a significant risk factor for delivering an IUGR infant. This underlines the importance of maternal education in determining a host of health related behaviour/practices. Factors relating to the care of women, environmental hygiene and sanitation, household food security and poverty are all likely to operate simultaneously with a low level of maternal illiteracy in the aetiology of IUGR. Osrin and Prost [35] assert that increasing maternal education increases pregnancy outcomes, maternal and child mortality. Quality antenatal care further enhances this effect [4].

In Papua New Guinea 87% of the total population live in rural areas with poor to very poor access to health care and health education [13]. One third of all aid posts are closed and outreach services from health centres to rural remote villages to provide essential care such as nutritional surveys, antenatal care and family planning have stalled from a previously unacceptably low level [21].

Lastly and of relevance, AA works in her own market garden which is the only source of income for her family. Hard physical labour increases maternal demand for nutrients. In addition to this increased energy demand, the postural effects associated with load bearing may compromise the flow of blood to the uterus, thereby limiting the availability of nutrients to the placenta and foetus [33]. In a study in PNG Allen et al [32] found a significant association between pre-term delivery and the mother working in a garden.

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Conclusion

AA is from a poor socioeconomic background, is uneducated, multiparous and works in a garden. She is undernourished, anaemic and has suffered from repeated malarial infections throughout and in between her pregnancies. This plethora of risk factors would surely guarantee a poor pregnancy outcome for both mother and child. AA seems fortunate to have not suffered any further overt morbidity from this pregnancy although its burden will have taken its toll. Her child was born prematurely and with intrauterine growth restriction and as Case Study Two demonstrates went on to experience substandard care in the provincial hospital.

Despite her health records indicating that this was an un-booked pregnancy (i.e. less than two antenatal visits) if AA’s health record is studied closely it becomes obvious that, although she may appear to have booked late she had been told that she had suffered a miscarriage in June and then possibly thought that she was pregnant again immediately. It would appear that she either had a threatened abortion or aborted a twin in June but retained the second foetus. If she thought that she had become pregnant again then her ante natal booking would be appropriate. Her care was not.

Evidence suggests that substantial reductions in maternal malaria, anaemia, undernutrition and subsequently, neonatal LBW and infant and child mortality can be achieved through intervention programmes targeted at existing antenatal services. Malaria is seen as an important contributor to the self perpetuating cycle of poverty and malnutrition. Intermittent preventive treatment for malaria, the use of insecticide treated bed nets, counselling about good nutrition, iron and folate supplementation and the treatment of hookworm to help prevent anaemia may contribute to reducing adverse pregnancy outcomes by 25-90%, is cost effective and saves lives [17]. Osrin and Prost [35] caution that although it has been thought that iron or other micronutrient supplementation should be beneficial to pregnancy outcomes, little evidence exists that supports this theory. Nutritional screening and culturally appropriate nutritional counselling may therefore be a more suitable intervention.

Papua New Guinea’s health indicators are poor and although some advances have been made, these are largely insufficient to make any meaningful progress towards the better health of the nation. Within a larger framework, a failure to provide proven effective interventions will greatly contribute to the burden of both maternal and infant mortality worldwide.

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References

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2. UNICEF. State of the world’s children 2009. Maternal and newborn health. New York: UNICEF; 2009 [cited 2010 September 17]; Online.

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4. Mahajan SD, Singh S, Shah P et al. Effect of maternal malnutrition and anaemia on the endocrine regulation of fetal growth. Endocrine Research 2004; 30 (2): 189-203.

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13. World Health Organization. World Malaria Report Geneva: WHO; 2008 [cited 2011 February 16]; Online.

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25. Tiono AB, Ouedraogo A, Bougouma EC. Placental malaria and low birth weight in pregnant women living in a rural area of Burkina Faso following the use of three preventive treatment regimens. Malaria Journal 2009; 8: 224.

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26. Mola G. Manual of Standard Managements in Obstetrics and Gynaecology for Doctors, H.E.O.s and Nurses in Papua New Guinea 6th Edition 2010. Port Moresby: Ministry of Health.

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34. Muthayya S, Kurpad AV, CP Duggan CP et al. Low maternal vitamin B12 status is associated with intrauterine growth retardation in urban South Indians. European Journal of Clinical Nutrition 2006; 60: 791–801.

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