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Nigerian J Paediatrics 2016 vol 43 issue 3

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2a locally named unclear condition that causes failure to thrive amongst the under five children in south-eastern Nigeria
Niger J Paediatr 2016; 43 (4): 240 - 245
ORIGINAL
Ezeonu CT
‘NTA’, a locally named unclear
Igwe DN
Anyanwu OU
condition that causes failure to
Ezeanosike OB
thrive amongst under five
Ojukwu JO
children in southeastern Nigeria:
Onoh E
An assessment of mothers’ and
Nweze JD
caregivers’ perception of its
causes and management
DOI:http://dx.doi.org/10.4314/njp.v43i4.2
Accepted: 4th August 2016
Abstract : Background: The age
( 190/231) reported peak occur-
old childhood condition locally
rence between the ages of one to
Ezeonu CT (
)
called ‘NTA in most South east-
three months. Features were;
Anyanwu OU, Ezeanosike OB
ern parts of the country Nigeria is
Weight loss (94.4%), Excessive
Ojukwu JO, Onoh E, Nweze JD
Department of Pediatrics,
unclear and a challenge to health
cry (89.2%), Dry skin (87.9%),
Federal Teaching Hospital, Abakaliki,
care professionals whose patients
Restlessness (86.6%), sleepless-
Ebonyi State, Nigeria.
refuse orthodox medicine
and
ness (80.5%), appearance of whit-
Email; ctezeonu@gmail.com
choose alternative medicine. This
ish/dyspigmented hair on skin
study was to find the typical fea-
(77.6%), etc. Most respondents
Igwe DN
tures of this condition as per-
were unsure of cause, some as-
Department of Medical Microbiology &
ceived by the populace
sume infective and fewer assume
Parasitology, Federal Teaching
Method: Two hundred and twenty
dietary cause. A total of 82.7%
Hospital, Abakaliki, Ebonyi State,
six questionnaires on symptoms
(191/231) reported that the tradi-
Nigeria
and signs were satisfactorily filled
tional healers were the best manag-
by participants residing in parts of
ers of ‘NTA’
Ebonyi state, southeast Nigeria.
Conclusion: The level of belief in
Data were analysed using SPSS
the existence of ‘NTA is signifi-
version 15. Cross tabulations and
cant and deserves a research into
comparison of means were done
the cause of the condition. The use
using chi square with level of
of alternative medicine is indeed a
significance set to p<0.05.
challenge for us to use reason and
Results: Over 90% (217/231) of
wisdom to deal with culture, belief
the respondents including Nurses
and illnesses.
and community health extension
workers, believed in the existence
Key words: Alternative medicine,
of ‘NTA with significant varia-
failure to thrive, , south-eastern
tion across levels of education
Nigeria, under five children
(p=0.019); A total of 82.3%
Introduction
causes are often associated with abnormal interactions
between the caregiver and the infant or child while the
Failure to thrive has been defined in a range of ways,
organic causes are often associated with medical condi-
with no overall accepted definition but an essential ele-
tions or systemic pathologies which may lead to inade-
ment is subnormal growth or weight gain. It is a sign of
quate energy intake, poor absorption and/or the inability
under nutrition, which may result from many biologic,
to use absorbed nutrients, and increased metabolic de-
mands. There is increasing recognition that in many
1
psychosocial and environmental processes, singly or in
combination
1, 2
. It is a disease more likely to be diag-
children the cause is multifactorial.
Furthermore, in
nosed in a child than in an adult. It takes a careful his-
more than 80 percent of cases, a clear underlying medi-
cal condition is never identified.
4
tory and physical examination to identify the most likely
cause of failure to thrive in a child. The definition of
failure to thrive however faces problems as no one sin-
The condition locally called ‘NTA in south eastern
gle criterion can be used to achieve a proper definition .
3
parts of Nigeria, has been observed to present clinically
The causes are classified into organic (medical) and
as failure to thrive. It is a condition that commonly af-
nonorganic (social or environmental). Nonorganic
fects infants, characterized by poor weight gain or pro-
241
gressive weight loss amongst other symptoms. As of
were selected based on their ability to communicate
now, there is no available literature on this condition. It
effectively. This background work of focus group dis-
is not yet clear whether the condition is a disease or a
cussion took us about two months, between February
disorder or whether the cause is organic or inorganic. In
and April as it entailed visiting some sub urban areas
other words, the actual cause of the condition is yet un-
and rural areas where some of the traditional healers
known although some of its victims have been success-
resided. Some of the local women, the community
fully managed at home by the traditional healer, using
health extension workers and some trained nurses were
herbs. This makes most mothers to refuse orthodox
involved in this discussion. The discussion was moder-
medical management and so prefer to seek herbal treat-
ated by one of the researchers and was audio and video
ment once their relatives suspect '‘NTA .
recorded and as well documented in writing. This inter-
Every culture has beliefs about health, disease, treat-
action gave us some reasonable information which we
ment, and health care providers. People tend to bring
used to develop the questionnaire. The questions were
their beliefs, and the practices that accompany them,
grouped into sections A and B. Section A contained in-
into the health care system and this often proves chal-
formation on the bio-data of the respondents while Sec-
lenging to health care professionals who have been
tion B was on case definition or symptomatic features
trained in the philosophy, concepts, and practices of
such as fever, excessive cry, weight loss, degree of ap-
orthodox medicine. The local condition called ‘NTA
5
petite for food, known cause, known outcome etc.. The
has been a controversial issue between health care pro-
answers to the questions in section B were graded on a
fessionals and the general population in the south east-
three point scale of Yes, No , or Not sure.
ern Nigeria. This often proves challenging to health care
professionals. It places one at the dilemma on how to
Ethical approval to conduct this study was obtained
prove the relatives or the general populace wrong or
from the Ebonyi state University Research Ethics Com-
right. To prove or disprove the local entity called ‘NTA
mittee. The questionnaires were administered to about
is an issue that requires scientific backing. So far, the
two hundred and fifty participants who had given their
aetiology like many other factors associated with failure
informed consent to partake in the research after due
to thrive appears to be unknown
1-3
and its course is not
explanation of our objectives. Confidentiality of re-
fully understood.
sponses was ensured by the maintenance of anonymity
in the questionnaires. The questionnaires were self-
In our practice, within the Federal Teaching Hospital,
administered to some participants according to their
Abakaliki, a tertiary health institution in the south-
capabilities while the rest were researcher-administered.
eastern Nigeria, there has been recurrent incidents of
To cover a significant variety of the populace, question-
children admitted with features of 'Failure to thrive' who
naires were distributed with the help of community
were taken away against medical advice by their parents,
health extension workers covering some of the local or
because of pressure from relatives, who believe that
district health centers. Eventually, two hundred and
‘NTA is the cause and should be better presented to the
twenty six questionnaires were analysed while the rest
traditional healer for treatment. Indeed, some of these
were discarded due to significant information gaps.
patients actually do well on herbs thus strengthening
Data collected were analysed using SPSS version 20.
their confidence in alternative/herbal medication. This
Cross tabulations and comparison of means were done
general belief in the remedial effect of herbs from the
using chi square, spearman correlation was used to com-
traditional healer on this condition poses a challenge to
pare the ordinal variables and the level of significance
orthodox medicine, one of the many conflicting situa-
was set to p<0.05.
tions encountered between orthodox and unorthodox
medicine. However, it may be wise to say that respect-
ing patients’ ideas about what should work as treatment
may be the only way to help the patient effectively.
6
Result
This study is a preliminary baseline study to identify the
common symptomatic features of the condition called
Over ninety percent (217/213) of the respondents be-
‘NTA and to find out the general knowledge and the
lieved in the existence of the condition called ‘NTA’.
attitude of the people on the causes and management of
There was no significant variation in belief across the
‘NTA .
age groups (p= 0.58). Across the various levels of edu-
cation, the affirmation to existence of ‘NTA’ was
strongest amongst the respondents with primary and no
formal education. Generally, greater than ninety percent
Subjects and methods
of respondents who had Higher Diploma and below in
education, believed in ‘NTA’, whereas, 86.9% of those
This study was carried out within Ebonyi State from
with University education believed in the existence of
February 2014 to September 2014. Our study instrument
‘NTA’. The variation between levels of education was
was a questionnaire which had been structured follow-
statistically significant (p=0.019; spearman; 0.018).
ing a focus group discussion held by the researchers
Across the occupational groups, it was interestingly
with some selected local women, health workers and
found that 88.2% (15/17) of the registered/certified
two traditional healers met at two different parts of the
nurses who participated, believed in ‘NTA’ and 100%
study area, one suburban and the other rural area. They
(33/33) of the community health extension workers who
242
participated believed in the condition.
Amongst the
Concerning the best treatment option for ‘NTA’, 82.7%
traditional healers, 91.7% (11/12) believed in ‘NTA’.
(191/231) reported that the traditional healers were the
However, there was no statistically significant variation
best managers of ‘NTA’. This was the option more fre-
across the occupational groups.
quently chosen across all age groups, levels of education
On the cause of ‘NTA , 32.9% (76/231) of the respon-
and occupation except among the registered nurses,
dents, were not sure of the cause, 29.4% (68/231)
where 64.7% (11/17) reported that the case should be
thought it was some infection, while 15.6% (36/231)
referred to a pediatrician. There was some significant
thought it was of dietary cause. This observation did not
variation within the levels of education (p=0.004) (see
vary significantly with age, but it varied significantly
Fig 2) where over 80% of respondents within the levels
across occupation (p=0.00) and level of education
of secondary education and below reported that the con-
(p=0.03), ( see Figure 1 & 3). Most of the Community
dition is better managed by the traditional healer and
Health Extension Workers (CHEWs), the registered
only 60.9% (14/23) and 75.6% (34/45) of the Higher
nurses and the other Civil servants (who were not health
Diplomas and University degree holders respectively
workers) thought the cause was an infection. Amongst
supported that traditional healers were the best option.
the majority of traders and farmers, the response was
The variation of choice of treatment across occupations
‘not sure’. The commonest response concerning cause
was also seen to be significant. (p=0.00).
amongst those with no formal education was ‘not sure
The commonest age at presentation of ‘NTA’ was said
(21.7%), followed by infection. Commonest response
to be at less than one month by 42.9% (99/231) and be-
from those with primary education was ‘not sure’ also
tween 1 -3 months old, by 39.4% (91/231) of respon-
followed by infection. Similar responses cut across those
dents. Much fewer respondents, indicated presentation
with secondary education and above. The general trend
after the age of three months (Figure 4).
of response to cause in descending order was ‘Not sure’
On prognosis, 40.7% 0f respondents reported that very
being greater than Infection which is followed by dietary
few children survive ‘NTA’, whereas, 32.5% (75/231)
causes.
reported that most children would survive ‘Nta’. Major-
ity of the respondents were not sure of any disability
Fig 1: Perceived cause of NTA with respect to the people’s occupation
arising from ‘NTA’.
Fig 4: Pie chart illustrating the age of NTA presentation
Fig 2: People’s level of education and their opinion on the best way to
manage NTA
A look at the various symptomatic presentations of
‘NTA’ in their order of commonest to the least common
feature shows ; Weight loss (94.4%), Excessive cry
(89.2%), Dry skin (87.9%), Restlessness (86.6%), sleep-
lessness (80.5%), appearance of whitish/dyspigmented
hair on skin (77.6%), Weakness (74.9%), Fisting of
palms (72.5%), Aggressive eater (71%), Fever (70.6%),
Widened anterior fontanelle (55%), Connected anterior
and posterior fontanelle (47.6%), Cough (34.2%). By
Fig 3: The perceived cause of NTA with respect to the people’s
this, it appears that weight loss, excessive cry, dry skin
level of education
and restlessness are most frequent features seen in chil-
dren with ‘NTA’.
Discussion
Culture and personal belief play a vital role in the health
seeking behaviour of the people. Culture influences
7
health and the management of illnesses, and issues re-
243
lated to culture can sometimes heighten risks or impact
propriately. This is not to say that the physician should
care. Culture may influence the belief about what
8
be controlled by patients’ choices but that he must learn
causes diseases, whether to engage a certain health pro-
to respect patients’ culture and adapt styles that will be
motion activity or seek advice regarding health concerns
helpful to the patient while encouraging patient’s partici-
or which treatment options are to be followed. It is
pation in his own health care. By so doing, the physician
known that culture also plays a role in the level of fam-
is building a relationship that focus on increasing the
ily influence in patient care decision. It is of little sur-
9
opportunities and choices of individuals and communi-
prise that there was a near consensus opinion that ‘NTA’
ties to access health care. This is termed cultural
safety. This relationship allows the physician to further
19
can only be treated best by alternative/traditional medi-
cine. Alternative medicine is a term used to refer to
explore and analyze a chosen alternative therapy or re-
medical products and practices that are not part of
search on the illness itself.
standard care (given or taught in the medical schools)
which are used in place of standard medical care
The participants in this research cut across various ages,
whereas Complementary medicine is used to describe
educational levels and occupation. They generally
the use of alternative medicine alongside standard or
seemed to share similar perceptions about ‘NTA’. The
orthodox medicine.
10
aetiology appears unknown and its course not fully un-
The use of complementary medicine is not at all new to
derstood. The description for the local condition ‘NTA’
medical history. It is a fact that the use of complemen-
fits into a situation of failure to thrive. However,
tary and alternative medicine (CAM) is on the increase
whether it is of organic or of non- organic origin is un-
globally with a high prevalence in developed coun-
clear. Looking at the constellation of symptoms as com-
tries. In developing countries, about 80% of the popu-
11
monly indicated, which includes weight loss despite
lation are dependent on traditional healing methods,
aggressive appetite, excessive cry, Dry skin, sleepless-
including herbal remedies, for health maintenance and
ness and restlessness, one may think of Protein energy
therapeutic management of diseases. CAM use in
malnutrition or Marasmus, From the focus group discus-
acutely ill children has been reported in Nigeria, tradi-
sion with some people, ‘NTA’ was said to occur
tional/herbal medicines being the most frequently used
amongst any social class and so it did not appear to be a
CAMs.
12.13
It has often times been a challenge to ortho-
consequence of lack of food otherwise the rich or the
dox medicine. Patronage to CAM by some individuals
high socioeconomic class would not be affected. The
may be for certain reasons that are not fully attributable
cause had been suspected to be of either infection or
to culture. About 85% of Nigerians are known to use
simply unknown. One thing they did know was that
and consult traditional medicine for healthcare, social
most of the patients responded well to the herbal medi-
and psychological benefits because of poverty and disil-
cations hence the increasing patronage that the tradi-
lusionment with conventional medical care
14
tional healers enjoyed.
Some authors have reported that alternative medicine
The picture of poor weight gain despite a good appetite
allows for patient’s control and active participation in
or increased feeding brings to mind endocrine disorders
one’s care which has been associated with better out-
such as diabetes mellitus or hyperthyroidism but then if
come. Some other reasons of concern is that some pa-
15
the condition is endocrine why would it respond dra-
tients have expressed negative comments about their
matically once and for all, to herbs given over a two to
interaction with their physicians, making them prefer to
four weeks period? Excessive crying in babies aged be-
use alternative medicine.
16
Wilcox and Bodekar in their
tween 0 – 3 months is often associated with Colic.
paper aptly noted that with increasing challenge of drug
Could the commonly noted excessive cry be due to a
resistance, affordability and availability of good quality,
concomitant colic or is it pathology of the ‘NTA’. The
safe and effective medicine in developing countries,
respondents also mentioned the presence of an unusually
herbal medicine have become a very important option in
open anterior fontanelle which usually extends to the
our health care system. The use of alternative medicine
17
glabella anteriorly and seemingly connects with the pos-
has become quite significant in every society. It is no
terior fontanelle. Studies have consistently reported that
longer an option to ignore it or treat it as something that
the size of the anterior fontanelle usually increases dur-
is outside the normal process of science and medicine. It
ing the first month of birth before it begins to reduce and
eventually close.
20
only challenges us to move forward carefully using both
reason and wisdom as we attempt to separate the pearls
from the mud. . However, it may be a source of worry,
18
The size of the anterior fontanelle reflects the balance
that alternative medicine is usually adopted long before
between brain growth and skull, and can reflect skeletal
scientific evidence has established its safety and effi-
morphogenesis. Many conditions are associated with
ciency .
18
large anterior fontanelle and they include hypothyroid-
ism, rickets, malnutrition, hypophosphatemia, osteo-
Because of culture and ethics of autonomy and justice, it
genesis imperfect, achondroplasia and some Trisomi-
es
13,8,21.
becomes necessary that a physician should play safe,
Some other conditions like the congenital Ru-
such that he gives room to appreciate the diversity be-
bella syndrome, syphyllis and prenatal exposure to drugs
tween his culture and that of his patients. It takes a cul-
like angiotensin converting enzyme inhibitors, meth-
turally competent doctor to recognize patient’s own and
otrexate, fluconazole, primidone etc, may be associated
with large fontanelle In general, the child with ‘NTA’,
22
one’s own sociocultural background and use skills ap-
244
fails to thrive. The common causes of failure thrive
south eastern Nigeria. We were unable to undertake the
within the first three months of life include feeding diffi-
clinical and laboratory analysis of cases of ‘NTA’ in the
culties, infections, gastroesophageal reflux, inborn errors
present study since our intention is to provide base line
of metabolism, cystic fibrosis and milk-protein intoler-
information on the perception of the mothers and care
ance. It is expected that infants double their birth weight
givers regarding ‘NTA’. A more complex study design
by the first four to six months of birth. Maximal brain
taking into account the clinical and laboratory assess-
growth also occurs within the first six months. A child
ment is recommended in future studies.
who has gone seven weeks without regaining her birth
weight deserves a thorough work up to determine the
cause. This would include a detailed feeding history and
a careful physical examination. If the cause is not clear
Conclusion
from the above, investigations such as complete blood
count and differentials, urinalysis, serum electrolytes,
Culture greatly influences medical care and beliefs influ-
urea and creatinine and stool analysis for malabsorption.
ence health seeking behavior and response to treatment.
If these do not yield a result, further investigations
Effective communication however, is central to high
would include a thyroid function test, liver enzymes,
quality therapeutic interaction. It enables greater in-
ammonia, lactate pyruvate, sweat – chloride test etc.
volvement of patients in their own care, better outcomes
and increased satisfaction.
23
The existence of ‘NTA’ as an unclear condition that
makes an infant to thrive poorly appears to be real. The
unanswered question is the type of condition it is. Is it a
Conflict interest: None
disease or a disorder? Is it caused by some pathogens or
Funding: None
is it due to some physiological or biochemical imbalance
in the child’s system. What are the therapeutic compo-
nents of the herbs commonly used in the treatment of
Acknowledgement
this condition? To answer the above questions, one
needs to do a comprehensive research and pathological
We wish to acknowledge the support rendered by Dr.
analysis of available case series. It is our opinion that
Efunshile of the Department of Pathology, Federal
community perceptions about diseases and their man-
Teaching Hospital, Abakaliki Nigeria, for his advisory
agement should not be ignored but rather should be ex-
role in the structuring of the questionnaire and Dr Uneke
plored, appreciated and corrected where necessary when
C.J of the Directorate of Research and innovation,
enough evidence is gathered on the safety and dangers
Ebonyi State University, Abakaliki Nigeria for his
of a particular mode of therapy.
expert review and encouragement. We also thank the
various traditional healers for their openness and will-
Study limitations
ingness to enlighten us on the traditional management
and features of ‘NTA’. We appreciate all who willingly
We could not extend the scope of this study beyond the
filled the questionnaires.
Reference
1.
Emond A, Drewett R, Blair P,
6.
Kielich AM, Miller L. Cultural
10. World Health Organization,
Emmett P. Postnatal factors associ-
aspects of women's health care.
WHO traditional medicine strat-
ated with failure to thrive in term
Patient Care. 1996; 30(16):60-76)
egy 2002 – 2005. WHO, Geneva;
infants in the Avon Longitudinal
7.
Chukwuneke F.N., Ezeonu C.T.,
2002.
Study of Parents and Chil-
Onyire B.N., Ezeonu P.O., Ifebu-
11. Oshikoya KA, Njokanma OF,
dren. Arch Dis Child . 2007;92
nandu N., “Culture and Biomedical
Bello JA, Ayorinde EO. Family
(2):115 – 119.)
Care in Africa: The Influence of
self-medication for children in an
2.
Cole S.Z, Lanham J.S. Failure to
Culture on Biomedical Care in
urban area of Nigeria. Paediatr
thrive: An Update. Am Fam Physi-
Traditional African Society, Nige-
Perinat Drug Ther. 2007;8:124 –
cian, 2011; 83 (7): 829 - 834.
ria, West Africa. Niger J Med.
130.
3.
Olsen EM. Failure to thrive: still a
2012; 21 (3) : 331-3
12. Oshikoya KA, Njokanma OF,
problem of definition. Clin Pediatr
8.
Canadian Medical Protective Asso-
Bello JA, Ayorinde EO. The use
(Phila) . 2006;45(1):1 – 6.
ciation (CMPA), https://
of prescribed and non-prescribed
4.
Stephens MB, Gentry BC, Mich-
www.cmpa-acpm.ca/-/when-
drugs in infants in Lagos, Nigeria.
ener MD, Kendall SK, Gauer R.
medicine-and-culture-intersect,
J Med Sci. 2008;8:111 – 117.
Clinical inquiries. What is the
accessed 25th January, 2016 ).
13. Adesina SK. Traditional medical
clinical workup for failure to
9.
World Health Organization.
care in Nigeria http://
thrive? J Fam Pract . 2008;57
‘Gender and Mental Health. June
www.onlinenigeria.com/links/
(4):264 – 266
2002, http;who.who.int; gender.
LinksReadPrint.asp?blurb=574
accessed 18 March, 2016).
th
5.
California Endowment. A man-
(accessed January 24, 2016 )
ager's guide to cultural competence
Alternative medicine http://
14. England SL. Evans J. Patient’s
education for health care profes-
www.medicinenet.com/
choices and perception after an
sionals. Los Angeles, CA: The
alternative_medicine/article.htm
invitation to participate in treat-
California Endowment, 2003.
accessed 5th February, 2016
ment decision. Soc. Sci Med;
1992: 34: 1217 – 1225.
245
15. Marshall RJ, Gee R, Israel M et al.
18. University of Victoria“ Cultural
21. Graham JM. Skull: In Stevenson
The use of alternative medicine by
Safety’ Module 1, 2013. Accessed
RF, Hall JG eds. Human malfor-
Auckland general practitioners. NZ
on Jan 24, 2016 at http; web 2.
mation and related anomalies,
Med J. 1990: 103; 213 – 215.
Urs.uvic.ca
2nd ed. New York, Oxford Uni-
16. Wilcox ML, Bodekar G. Tradi-
19. Pedroso FS, Roita N, Quintal A,
versity Press, 2006: 223 – 265)
tional herbal medicine for malaria.
Gordon G. Evaluation of anterior
22. Cooper-Patrick L. Gala JJ, VU
BMJ 2004, 329; 31 – 34.
fontanelle size in normal infants in
HT, Powe NR, Nelson C, Ford
17. Kelner M, Wellman B. Comple-
the first year of life. J Child neurol
DE. Race, gender and partnership
mentary and Alternative medicine,
2008; 23 (12): 1419 – 1423.
in the patient physician relation-
challenge and change:
20. Gallagher ER, Hing AV, Cunning-
ship. JAMA 1999:282(6);583
Routledge;2014, May 12
ham ML. Evaluating fontanelles in
589
the newborn skull. Contemporary
Pediatrics, 2013; 30 (11):12