Pediatric Development Clinic. An Integrated Model to Support Nutrition and Early Childhood Development of Vulnerable Infants and Children

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1 Pediatric Development Clinic: An integrated Model to Support Nutrition and Early Childhood Development of Vulnerable Infants and Children --- Presenter Hema Magge of Partners In Health: Forty percent 40% of child deaths occur in the neonatal period according to RDHS The project goal is to create a clinic to provide needed services targeting low birth weight children and track and evaluate the outcome. The services include follow-up clinic for early intervention for the nutritional, medical and developmental needs of at-risk infants. An objective is to provide high-quality care through screening, simple interventions, and caregiver counseling to support ECD. The project aims to demonstrate feasibility of model implementation with potential for national scale-up The primary population served includes infants with prematurity/low birth weight and birth asphyxia. Secondary population includes those withtrisomy21, Cleft lip/palate, Hydrocephalus and other developmental delay, neuromuscular disorder, suspected genetic syndrome Monitoring indicators include program monitoring, growth and feeding, medical danger signs, developmental screening and counseling, alerts, reminders and automated patient-level and aggregate reports generated from the EMR system. Outcomes of at-risk neonates after 1 year of implementation will be compared to those at baseline and results will be used to inform potential national scale-up with NCD service expansion. 32

2 Pediatric Development Clinic An Integrated Model to Support Nutrition and Early Childhood Development of Vulnerable Infants and Children 1

3 Co-Authors Hema Magge, MD, MS, Partners In Health Jean Claude Uwamungu, MD, Partners In Health Leonce Mwizerwa, MD, Rwanda Ministry of Health Thacien Twagirumukiza, MD, Rwanda Ministry of Health Evrard Nahimana, MD, Partners In Health Gedeon Ngoga, Partners In Health Francis Mutabazi, Rwanda Ministry of Health Cheryl Amoroso, MPH, Partners In Health Fulgence Nkikabahizi, MD, Rwanda Ministry of Health 2

4 Improving Neonatal Survival in Rwanda Significant neonatal mortality with 40% of childhood deaths occurring in neonatal period (RDHS 2010) Since 2010, national strategies focus on improving immediate neonatal survival with neonatal special care units Emerging group of vulnerable infants at higher nutritional, medical and developmental risk (ex. LBW, preterm) No systematic way of providing long term nutritional support, medical care, or ECD opportunities for these at-risk infants 3

5 Early Childhood Development in Rwanda Early childhood (0-5 years) is critical period of brain growth and affects long-term outcomes Adequate nutrition is essential to ensuring healthy brain growth and development during early childhood Challenges to early childhood development 44% of children in Rwanda are stunted (DHS 2010) Few have access to ECD opportunities Minimal opportunities for parental education and support Infants with perinatal complications have even higher biologic and social risk 4

6 Alignment with National Strategic Plans Rwanda Health Sector Strategic Plan Scale-up of post-natal services Post-natal service capacity development Community-centered ECD services Ministry of Education Integrated Early Childhood Development Strategic Plan Need for caregiver training Development of ECD services 5

7 Implementation Setting Southern Kayonza: 1 District Hospital, 8 health centers, 926 CHWs Population: 188,363 people (2012 Census) 3 health centers that provide noncommunicable disease (NCD) services with integrated EMR 6

8 Pediatric Development Clinic Goal 1 Create follow-up clinic for early intervention for the nutritional, medical and developmental needs of at-risk infants Provide high-quality care through screening, simple interventions, and caregiver counseling to support ECD 7

9 Goal 2 Prospectively track and evaluate medical and developmental outcomes of at-risk infants 8

10 Goal 3 Demonstrate feasibility of model implementation with potential for national scale-up District Hospital and Health Center levels 9

11 Program Overview Weekly nurse-led clinic housed within outpatient non-communicable disease services Training in basic nutritional, medical and developmental protocols Setting: 3 health centers in year 1, 2 additional health centers in year 2 Timeframe: 24 months Initiative led by MCH with NCD support Protocols approved by Rwanda Pediatric Association 10

12 Populations Served Primary: Infants with prematurity/low birth weight Birth asphyxia Secondary: Trisomy 21 Cleft lip/palate Hydrocephalus Other developmental delay, neuromuscular disorder, suspected genetic syndrome 11

13 Program Services Nurses and social workers provide: 1. Condition-specific medical screening 2. Monitoring of growth and nutrition 3. Developmental screening and care Screening using Ages and Stages questionnaire adapted to Rwanda (developed by CARE) UNICEF package for developmental intervention Social supports for vulnerable families meeting criteria: Transport fees Food packages Home visits by CHW as needed EMR integration for effective monitoring and evaluation 12

14 Trainings Training of NCD nurses in: PDC Clinical Protocol (developed by PIH) General ECD support (Care for Child Development - UNICEF) Specific ECD support based on developmental screening results (UNICEF) Training of Social Workers in: ECD kit for child-friendly space use (UNICEF) Training planned for March 2014 followed by immediate implementation and supervision 13

15 Clinic Flow Referral from hospital upon discharge and rendezvous given in Pediatric Development Clinic Arrival at clinic: 1) General ECD counseling provided by NCD nurse during morning group teaching session 2) Wait for consultation in child-friendly space with SW trained in ECD facilitating interactive play with children and caregivers 3) Individual consultation with NCD nurse providing medical, nutritional, developmental screening and counseling/treatment 14

16 Monitoring and Evaluation EMR monitoring indicators in process and outcomes for: Program monitoring Growth and feeding Medical danger signs Developmental screening and counseling Alerts, reminders and automated patient-level and aggregate reports generated from the EMR system Facilitate program monitoring and quality improvement activities 15

17 Monitoring and Evaluation Early qualitative assessment after 3 months of implementation to assess: Caregiver perceptions, value, and feedback to the clinic Nurse feedback on training effectiveness and protocol use Outcomes of at-risk neonates after 1 year of implementation will be compared to those at baseline Results will be used to inform potential national scaleup with NCD service expansion 16

18 Thank you Questions? 17

19 Pediatric Development Clinic An Integrated Model to Support Nutrition and Early Childhood Development of Vulnerable Infants and Children 1

20 Co-Authors Hema Magge, MD, MS, Partners In Health Jean Claude Uwamungu, MD, Partners In Health Leonce Mwizerwa, MD, Rwanda Ministry of Health Thacien Twagirumukiza, MD, Rwanda Ministry of Health Evrard Nahimana, MD, Partners In Health Gedeon Ngoga, Partners In Health Francis Mutabazi, Rwanda Ministry of Health Cheryl Amoroso, MPH, Partners In Health Fulgence Nkikabahizi, MD, Rwanda Ministry of Health 2

21 Improving Neonatal Survival in Rwanda Significant neonatal mortality with 40% of childhood deaths occurring in neonatal period (RDHS 2010) Since 2010, national strategies focus on improving immediate neonatal survival with neonatal special care units Emerging group of vulnerable infants at higher nutritional, medical and developmental risk (ex. LBW, preterm) No systematic way of providing long term nutritional support, medical care, or ECD opportunities for these at-risk infants 3

22 Early Childhood Development in Rwanda Early childhood (0-5 years) is critical period of brain growth and affects long-term outcomes Adequate nutrition is essential to ensuring healthy brain growth and development during early childhood Challenges to early childhood development 44% of children in Rwanda are stunted (DHS 2010) Few have access to ECD opportunities Minimal opportunities for parental education and support Infants with perinatal complications have even higher biologic and social risk 4

23 Alignment with National Strategic Plans Rwanda Health Sector Strategic Plan Scale-up of post-natal services Post-natal service capacity development Community-centered ECD services Ministry of Education Integrated Early Childhood Development Strategic Plan Need for caregiver training Development of ECD services 5

24 Implementation Setting Southern Kayonza: 1 District Hospital, 8 health centers, 926 CHWs Population: 188,363 people (2012 Census) 3 health centers that provide noncommunicable disease (NCD) services with integrated EMR 6

25 Pediatric Development Clinic Goal 1 Create follow-up clinic for early intervention for the nutritional, medical and developmental needs of at-risk infants Provide high-quality care through screening, simple interventions, and caregiver counseling to support ECD 7

26 Goal 2 Prospectively track and evaluate medical and developmental outcomes of at-risk infants 8

27 Goal 3 Demonstrate feasibility of model implementation with potential for national scale-up District Hospital and Health Center levels 9

28 Program Overview Weekly nurse-led clinic housed within outpatient non-communicable disease services Training in basic nutritional, medical and developmental protocols Setting: 3 health centers in year 1, 2 additional health centers in year 2 Timeframe: 24 months Initiative led by MCH with NCD support Protocols approved by Rwanda Pediatric Association 10

29 Populations Served Primary: Infants with prematurity/low birth weight Birth asphyxia Secondary: Trisomy 21 Cleft lip/palate Hydrocephalus Other developmental delay, neuromuscular disorder, suspected genetic syndrome 11

30 Program Services Nurses and social workers provide: 1. Condition-specific medical screening 2. Monitoring of growth and nutrition 3. Developmental screening and care Screening using Ages and Stages questionnaire adapted to Rwanda (developed by CARE) UNICEF package for developmental intervention Social supports for vulnerable families meeting criteria: Transport fees Food packages Home visits by CHW as needed EMR integration for effective monitoring and evaluation 12

31 Trainings Training of NCD nurses in: PDC Clinical Protocol (developed by PIH) General ECD support (Care for Child Development - UNICEF) Specific ECD support based on developmental screening results (UNICEF) Training of Social Workers in: ECD kit for child-friendly space use (UNICEF) Training planned for March 2014 followed by immediate implementation and supervision 13

32 Clinic Flow Referral from hospital upon discharge and rendezvous given in Pediatric Development Clinic Arrival at clinic: 1) General ECD counseling provided by NCD nurse during morning group teaching session 2) Wait for consultation in child-friendly space with SW trained in ECD facilitating interactive play with children and caregivers 3) Individual consultation with NCD nurse providing medical, nutritional, developmental screening and counseling/treatment 14

33 Monitoring and Evaluation EMR monitoring indicators in process and outcomes for: Program monitoring Growth and feeding Medical danger signs Developmental screening and counseling Alerts, reminders and automated patient-level and aggregate reports generated from the EMR system Facilitate program monitoring and quality improvement activities 15

34 Monitoring and Evaluation Early qualitative assessment after 3 months of implementation to assess: Caregiver perceptions, value, and feedback to the clinic Nurse feedback on training effectiveness and protocol use Outcomes of at-risk neonates after 1 year of implementation will be compared to those at baseline Results will be used to inform potential national scaleup with NCD service expansion 16

35 Thank you Questions? 17

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