Section on

International Child Health

Newsletter
Fall 2008

Notes from the Chair

Cliff Michael O’Callahan, MD, PhD, FAAP
Chairperson for the Section on International Child Health
[email protected]

Greetings all and here’s wishing you a good fall or spring. In the north, fall brings us the annual
meeting of the AAP and this year we shall meet in Boston. Those of us who are interested in child-
hood health on the global level will have quite a few opportunities to catch up with each other
and attend some great programs – especially our own Section’s program on Monday, and the
Christopherson lecture by Dr. Hoosen “Jerry” Coovadia on Tuesday during the plenary speeches.

I will be attending a number of ancillary meetings or gatherings and my role is to act as your rep-
resentative. For that reason I wish to share with you what I and many of the executive commit-
tee members will be doing and invite your thoughts, comments, and suggestions.

I will finish off this column with a plea for help in some of our activities...

International Pediatric Association: our executive committee will spend the first part of our day-
long business meeting gathering with representatives from the executive committee of the IPA.
We have worked together over the years on such efforts as the advocacy course in Cote d’Ivoire,
the environmental health series of courses held in conjunction with WHO, and the Disaster
Management course. We are looking forward to continually improving our working relationship
with this important and influential body.

Perinatal health: we will be meeting with representatives from the Section on Perinatal Pediatrics
to brainstorm ways in which our Sections might work synergistically on programs and projects.
Continued on Page 2

In this Issue . . . Experience in Tanzania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

International Volunteering: So What’s Stopping You? . . . . . . . . . . . . . . 12

Notes from the Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Canadian Paediatric Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
I-CATCH Tremendous Year Three Response for I-CATCH . . . . . . . . . . . 3
SOICH Book Repository Encounters Shipping Restraints . . . . . . . . . . 15
A Primer in Primary Maternal & Child Care Everywhere. . . . . . . . . . . . . 3
The Management of Childhood Chronic Renal Failure in the
Growth Monitoring, Promotion and Food Supplementation . . . . . 4
Developing World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Oral Rehydration Therapy/water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2008 National Conference & Exhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Resident International Elective Travel Grants . . . . . . . . . . . . . . . . . . . . . . 8
SOICH Executive Committee Members . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Peruvian Amazon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Copyright© 2008 by the American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the
publisher. Printed in the United States of America.
SOICH Book Repository Encounters Shipping Restraints Continued from Page 16
Rules:
• Donor can judge how current a text must be to be useful (e.g. Anatomy does not change, but PDR’s should
be up to date)
• Journals 10 years or less
• Donations must be delivered to warehouses in San Francisco or Chicago

Letter acknowledging receipt of the books is sent to the donor.

Jeff Smith, Ed.D., President

Bridge to Asia
665 Grant Ave
San Francisco, CA 94108
Tel. 415-678-2994
Fax: 415-678-2996
e-mail: [email protected]
www.bridge.org - Website provides all details about shipping and collection sites.

So, for the moment, please consider donating appropriate medical books to the organizations above or oth-
ers that are listed at the AMSA website. As soon as other mailing/shipping options become available to the
SOICH Repository, we’ll let you know. And THANK YOU to all who have donated books in the past!!

The Management of Childhood Chronic Renal Failure

in the Developing World
Aamir Jalal Al-Mosawi M.D, Ph.D.,
President of the Iraqi Society of Pediatric Nephrology
Professor and Head of the department of pediatrics
University Hospital in Al Kadhimiyia
Baghdad Iraq

In recent years, confronted with the unpalatable spectacle of the suffering patients
with ESRD, I have been using a novel therapeutic strategy to provide such patients
with freedom from dialysis and an improved sense of wellbeing.

Chronic kidney disease has become a worldwide public health problem: tithe chal-
lenge remains enormous

There has been a dramatic increase in the incidence of chronic renal failure (CRF) dur-
ing the past two decades. Chronic kidney disease has become a worldwide public
health problem. More than one million individuals in the world are on maintenance
dialysis, a number that is estimated to double in the next decade. Access to dialysis
is significantly different between developed and developing nations. Close to 80% of the world dialysis popu-
lation is treated in Europe, North America, and Japan, representing 12% of the world’s population. The remain-
ing dialysis patients are treated in the developing world. This disparity is likely due to the high cost and
complexity of renal replacement therapy (RRT). Dialysis is so costly that is out of reach for low-income coun-
tries, which are struggling to provide alternative therapeutic measures in renal care. Peritoneal dialysis seems
a good, affordable, therapy for patients living in areas where hemodialysis is not available. In fact, despite sub-
stantial improvements in the science and technology of RRT, the morbidity and mortality of patients with ESRF
remain excessively high in many countries .Of more than 450.000 patients with ESRD in USA ,more than 79
000 died in 2004 [1-5]

Dialysis patients leads a highly abnormal life, suffer from poor quality of life and shorter life expectancy com-
Continued on Page 18

Section on International Child Health Page 17

The Management of Childhood Chronic Renal Failure . . . Continued from Page 17
pared to individuals of the same age and sex in the general population. Patients undergoing various forms of
maintenance dialysis are tethered to a machine to extent unprecedented in the history of medical technology.
All dialysis patients find themselves abjectly dependent on a procedure, medical facility, and medical person-
nel. Approximately one of every 500 dialysis patients commits suicide. A larger number unsuccessfully try sui-
cide on one or more occasion . Despite a tremendous increase in knowledge and skill in the management of
ESRD patients such individuals, particularly those treated by dialysis, remain unwell. Impaired quality of life,
dependence on others and poor rehabilitation all contribute to the physical and emotional disabilities that may
persist even in the well dialyzed ESRD patients [6-9].

The incidence of ESRD in Asian developing countries is likely to be higher than that reported from the devel-
oped world. The vast majority of patients starting hemodialysis die or stop treatment within the first three
months, because of cost constraints. Less than 2% of patients are started on ambulatory peritoneal dialysis.
Although renal transplantation is the cheapest option, only about 5% of all patients with ESRD end up having
a transplant. Living related donor transplants constitute 30 to 40% of all transplants in India, but there is a con-
spicuous gender bias with female donors donating kidneys for their male relatives. There is no organized cadaver
donation program and an overwhelming majority of transplants are performed using living donors. This led
to the practice of the sale of kidneys for transplant. The financial burden of RRT in developing nations impacts
on the lifestyle and future of entire families, and extracts a cost far higher than the actual amount of money
spent on treatment [10-18].

The ultimate resolution of these problems requires a fundamental breakthrough in our knowledge regarding
prevention and cure of many different processes that destroy kidneys. Although the rapidly growing body of
information may provide this breakthrough for many progressive renal diseases, it’s unlikely that this informa-
tion will lead us to the prevention or cure of all the disorders leading to ESRD..

Management of end-stage renal failure

Conservative measures are only successful in non-terminal chronic renal failure (CRF) patients, and in patients
with end-stage renal failure (ESRD) with glomerular filtration rates less than 5% of the normal who cannot sus-
tain life in the absence of renal replacement therapy (RRT), and either dialysis or transplantation is required .
RRT is widely available in industrialized countries. In developing countries it is not uniformly available, so
patient management often relies on conservative measures and intermittent peritoneal dialysis (IPD). However,
ESRD patients treated in such a way may die from uremia and complications of IPD [19] .

The need for a robust rather than advanced sophisticated but expensive technology
The need for a robust rather than advanced sophisticated but expensive technology when resources are lim-
ited has been emphasized by Russell W Chesney and Andrea B Patters [20]. The attitude of governments in eco-
nomically disadvantaged countries is giving priorities to improving the basic level of their health services rather
than to expensive therapies that affect only a small number of the population is logical. Remember that the
expensive RRT has been disappointing in a certain number of patients who didn’t have a successful transplant.
In fact RRT is so expensive that it is beyond the affordability of all patient but the patients living in extremely
wealthy countries unless the costs are covered by the governments. The difficulty in selecting patients for this
life saving treatment according to their ability to pay for the treatment has created a serious ethical problem.
It’s also ethically puzzling not to offer treatment for patients who can pay merely because the treatment is not
universally available. It’s also understandable that, there is no obligation on doctors to preserve life at all cost,
however it’s hard for the patients to accept that they are not provided a life saving treatment because of social
priorities favoring spending on housing or education.

The management of ESRD in the developing world: Is there any alternative

The lack of effective RRT in many areas in the world should not mean that the patients with ESRD are left with-
Continued on Page 19

Page 18 Section on International Child Health

The Management of Childhood Chronic Renal Failure . . . Continued from Page 18
out other suitable care. In recent years, confronted with the unpalatable spectacle of the suffering patients with
ESRD, I have been using a novel therapeutic strategy to provide such patients with freedom from dialysis and
an improved sense of wellbeing. I hope that this new therapeutic approach could contribute to the partial solu-
tion of one of the ethical dilemma surrounding the provision of RRT. This new model of treatment provides a
novel paradigm for the management of such patients giving them the best quality of care possible [21-29].

In a series of 80 patients with CRF, 14 patients (16.5%) were treated with a new therapeutic approach consist-
ing of acacia gum supplementation plus the traditional conservative measures. This resulted in amelioration
of the uremic symptoms and lowering of blood urea levels and delaying the need for dialysis. In this sample of
patients the longest survival of 5 years was achieved in 2 patients, both treated initially with IPD .One of them
was transplanted and the other was treated with combination of the traditional conservative measures and aca-
cia gum supplementation[27]. Furthermore, six -year dialysis freedom has been reported with this therapy.

References
1. UNITED STATES RENAL DATA SYSTEM. Excerpts from United states Renal Data System 1995 Annual Data Report. Am
J Kidney Dis 1995; 26(Suppl 2):S69-S84.
2. Fenton S, Desmeules M, Copleston P, Arbus G, Froment D, Jeffery J, Kjellstrand C .Renal replacement therapy in Canada:
a report from the Canadian Organ Replacement Register. Am J Kidney Dis 1995; 25(1):134-50.
3 Jager KJ, Merkus MP, Dekker FW, Boeschoten EW, Tijssen JG, Stevens P, Bos WJ, Krediet RT. Mortality and technique fail-
ure in patients starting chronic peritoneal dialysis: results of The Netherlands Cooperative Study on the Adequacy of
Dialysis. NECOSAD Study Group. Kidney Int 1999; 55(4):1476-85.
4. MallickNP, JonesE, Selwood N. The European (European Dialysis and Transplantation Association-European Renal
Association) Registery. Am J kidney Dis 1995; 25:176-187.
5. UNITED STATES RENAL DATA SYSTEM: USRDS 2004 Annual Data Report. The National Institute of Health, National
Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2004.Available at: http:// www.usrds.org.Aceessed
April 2005.
6. Abraham HS. Survival by machine; The psychological stress of chronic hemodialysis. Psychiatry Med 1970; 1:37 9.
7. Merkus MP, Jager KJ, Dekker FW, Boeschoten EW, Stevens P, Krediet RTQuality of life in patients on chronic dialysis: self-
assessment 3 months after the start of treatment. The Necosad Study Group. Am J Kidney Dis 1997; 29(4):584-92 8-
Kimmel PL. Depression as a mortality risk factor in hemodialysis patients. Int Jartif Organs 1992; 15:697.
19. Levenson JL, Glocheaski S. Psychologic factors affecting end-stage renal disease. A review .Psychosomatics 1991; 32:382.
10.. Chugh KS, Jha V. Differences in the care of ESRD patients worldwide: required resources and future outlook. Kidney Int
Suppl. 1995; 50:S7-13.
11. Jha V. End-stage renal care in developing countries: the India experience. Ren Fail. 2004; 26(3):201-8.
12-Agodoa LYC, Eggers PW. Renal replacement therapy in the United States: Data from the United States Renal Data System.
Am J Kidney Dis.1995; 25:119.
13. Ifudu O, Paul H, Mayers JD etal. Pervasive failed rehabilitation center-based hemodialysis patients. Am J Kidney Dis 1994;
23:394?
14. Evans RW. Quality of life assessment and the treatment of end-stage renal disease. Transplant Rev 1990; 4:28.
15. Harper AM, Rosendale JD. The UNOS OPTN Waiting List and Donor registry: 1988-1996.
16. Salonen T, Reina T, Oksa H, Sintonen H, Pasternack A. Cost analysis of renal replacement therapies in Finland. Am J Kidney
Dis. 2003; 42(6):1228-38
17. Valente JF, Alexander JW.Surgical Clin of N Am 1998; 78(1):1-
18. Sakhuja V, Sud K. End-stage renal disease in India and Pakistan: burden of disease and management issues. Kidney Int
Suppl. 2003 ;( 83):S115-8.
19. Al-Mosawi AJ. Acacia gum therapeutic potential: possible role in the management of uremia – a new potential medi-
cine. Therapy 2006; 3(2) 301-321
20. Chesney RW, Patters AB. Acacia gum in chronic renal failure. Therapy 2006; 3 (2): 183-185
21. Al-Mosawi AJ. Acacia gum supplementation of a low- protein diet in children with end-stage renal disease. Pediatr
Nephrol 19; 1156-1159 (2004).
22. Al Mosawi AJ. The use of acacia gum in end stage renal failure .J Trop Pediatr. 2007; 53 (5):362-5.
23. Al-Mosawi AJ. The challenge of chronic renal failure in the developing world. Possible use of acacia gum. Pediatr.
Nephrol.17, 463–464 (2002).
24. Al Mosawi AJ. Continuous renal replacement in the developing world: Is there any alternative. Therapy (London)
2006:3(2): 265-272.
25. AJ Al Mosawi. Comprehensive conservative management of ESRF: three –year dialysis freedom. Pediatr Nephrol 2006;
21(10): 1600.1601. (Abstracts: The 40th annual meeting of the ESPN October 7-10 Palermo Italy www.espn2006.org).
26. AJ Al Mosawi. A Beneficial Effect of Acacia Gum in a Patient with Nephropathic Cystinosis and Chronic Renal Failure
Pediatr Nephrol 2007; 22 (9):1401-1650. (Abstracts: 14 the Congress of the International Pediatric Nephrology Association
2006-08-31 - 2007-09-04 Budapest, Hungary www.ipna2007.com/final_programme/index.html).
27. Al Mosawi AJ. Renal Failure (CRF): An extra-ordinary experience. Pediatr Nephrol 2007; 22 (12):2151-2175 (Abstracts:
Neprokids-WCN 07 Satellite symposium on Pediatric nephro-urological diseases April 27-April 29 Brazil).
28. Al Mosawi AJ. Urea lowering effect of acacia gum supplementation of low protein diet in patients with symptomatic ure-
mia. Journal of Renal Nutrition Volume 18, Issue 3, Supplement 1, May 2008, Page S48 Abstracts From the XIV
International Congress on Nutrition and Metabolism in Renal Disease.
29. Al Mosawi AJ. A new dietary therapy : Six year-dialysis freedom in End–stage renal disease. Journal of Renal Nutrition
Volume 18, Issue 3, Supplement 1, May 2008, Page S48 Abstracts From the XIV International Congress on Nutrition and
Metabolism in Rena

Section on International Child Health Page 19

 2008 National Conference & Exhibition
Section on International Child Health’s Annual Section Program
Monday October 13, 2008, Boston MA

8:00-9:00 am
Frontline Report: Current Strategies in the Management of Malnutrition

“The Impact of Community-based Therapeutic Care (CTC) on Selective Feeding Programs Worldwide”
Steve Collins, MD, Director, Valid International, Oxford, United Kingdom

Community-based Therapeutic Care was developed by Valid to improve the coverage and success of nutritional
rehabilitation programs for the treatment of acute malnutrition. Its central innovation is to provide therapeu-
tic feeding in the home in a manner that empowers communities and creates a platform for longer-term solu-
tions to the problems of food security and public health. The CTC approach has been used to treat nearly a hundred
thousand children and is now the basis for national protocol in several severely affected countries.

9:00-12:15 pm
HIV/AID in the Developing World, Update 2008
“The Pediatrics AIDS Corp Experience: Overview, Lessons Learned, and Notes from the Field”
Mark Kline, MD, Director, Baylor International Pediatric AIDS Initiative, Texas Children’s Hospital Clinical Care
Center, Houston, TX

The Baylor International Pediatric AIDS Initiative was established in 1996 and is the largest university-based pro-
gram worldwide dedicated to improving the health and lives of HIV-infected children. Supported by PEPFAR and
the Global Fund , the network includes centers in Botswana, Burkina Faso, Lesotho, Malawi, and Swaziland.

“Treatment of Pediatric HIV: an International Perspective”

Sunithi Solomon MD, Chennai, India

(10:30-10:45am Break)

“Is it feasible to eliminate perinatal HIV transmission globally?”

Hoosen M. Coovadia, MBBS,MD, University of KwaZulu-Natal, South Africa (Christopherson Lecturer 2008)

“The Treatment of Children with HIV/AIDS in Orphanages in Ethiopia and Vietnam:

Resource Limited Settings”
Jane Aronson, DO, FAAP, Founder and Director, Worldwide Orphans.

Since 1997, Worldwide Orphans Foundation (WWO) has been providing direct services to children in orphan-
ages through the volunteer work of Orphan Rangers which is a peace corps for orphanages. WWO was the first
NGO to provide ARVs for orphans in Vietnam and Ethiopia.

12:15-1:45pm
Lunch, Networking and Section Meeting
(residents and prospective section members welcome!)

2:00-2:30pm
Update on Iraq 2008 - What’s Happening in Pediatrics and how we can help.
Aamir Jalal Al-Mosawi M.D, Ph.D., President of the Iraqi Society of Pediatric Nephrology, Professor and Head
Continued on Page 21

Page 20 Section on International Child Health