Letters

Further down:
Pots and Pans
Nappies !!!
Dear Reader...
Field exchange addressed the following question to Prof Mike Golden of Aberdeen University

Dear Mike,
In a meeting a couple of weeks ago on 'infant feeding in emergencies' held at SCF HQ, a field worker from one of the NGOs present pointed out that in his experience feeding small infants with cup and spoon was a better technique than feeding with cup only (the option recommended by another group present). With cup alone the field worker said, mothers tended NOT to sit the baby upright, pour the fluid too eagerly and risk aspiration pneumonia - he was supported by other field workers in his assertions. What are your comments or recommendations on this.

Dear Field Exchange,
I have experience of both methods and am convinced that cup and saucer regimens are better. The possibility of inhalation pneumonia in the recovering severely malnourished child has concemed me for years. There is no information in the literature on lung function or aspiration pneumonia in the severely malnourished child at any stage of recovery. Nevertheless, examination shows that a very high proportion have stigmata of chronic chest disease, almost certainly due to repeated bouts of pneumonia, that could easily be precipitated by inhalation. There is a need for pulmonary physiological studies(lung-function tests) in children with severe malnutrition - if any one is interested in such a study please get in touch with me.
The practice that we followed since 1956, in Jamaica, has been to use a cup and saucer, without a spoon, for the liquid feeds; spoons and bowls were used for solid food later in recovery. Choking and inhalation were more common in later recovery when solid food was given by spoon than when milk was given by cup only.
There is a definite technique to feeding a malnourished child properly. It is not taught to the people who either train the local staff or to the mothers. The critical thing is to have the child physically on the lap of the person feeding the child, held securely in a "cuddle" against the chest, facing forward in an upright posture, with the mother's left arm encircling the child and holding the saucer under the chin. The right hand holds the cup for the child to drink. Any "dribbles" are collected in the saucer and retumed to the cup. The most important thing is to teach the mothers how to hold their children during feeding and to have someone who is properly trained watching the children as they are fed.

With a spoon and cup there are several problems that I have repeatedly witnessed.
1. The feeding is very slow. This is a major difficulty because one of the main functions of the attendants is to watch the children during feeding. Such surveillance is critical to ensure that the child gets the food and to assess the child's appetite. Rates of recovery improve with adequate surveillance as less is taken by the mother, none is shared with other siblings and more can be offered where the patient is hungry making feeding "to appetite" a reality.

2. There is a lot of spilt food. A lot of the milk "dribbles" down the front of the child and is lost. Investigation of poor weight gain, despite high calculated intakes, shows that up to a third of the meal can actually be spilt with improper feeding. Test weighings with the cup only method (weigh both the cup and the child before and after the feed), where a saucer below the chin catches the dribbles, gives a measured loss of just under 10%. With a spoon or with self-feeding the losses are much higher.

3. The child is often left to take the food him/herself. This is perhaps the most damaging feature of the spoon and cup. The child is not being cuddled and held during feeding and actively encouraged by the mother. Feeding is one of the most important times to show love and to psycho-socially stimulate the child - to talk to the child and have bodily contact.

4. Damage may occur during force feeding. If the child is reluctant to eat then the mother or aide frequently attempt to force the child's mouth open by pinching the cheeks, holding the nose and/or forcing the spoon between the lips. A spoon causes much more trauma to
a child's mouth than a cup. I have seen children with stomatitis receive quite deep cuts in their mouths from spoons.

5. It is during force feeding that inhalation is most likely to occur. As force feeding is much easier with a spoon than a cup, it is my experience that inhalation pneumonia is more common following feeding with a spoon (both food and medicines) than with a cup only.

Going round Therapeutic Feeding Centres in West Africa, where cups and spoons were being used, I demonstrated to the local staff and mothers how to feed their children with a cup and saucer. They have all since reported back that they find this method to be better, problems that they had, have resolved and weight gains have improved.

I would like to hear from those who have a different practical experience from mine; such practical aspects of feeding the child are very important but have never been satisfactorily addressed by scientific investigation.

    Yours, etc.,
    Mike Golden

 For further discussion on this subject contact Prof Michael H.N. Golden, Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, AB25 2ZD, Scotland, (UK). E-mail: m.golden@abdn.ac.uk

Pots and Pans



Dear Field Exchange

When recently thinking about a proposal on micro- nutrient initiatives for refligee women, I was reminded of a special after-dinner treat we sometimes eat in India. It is 'jaggery' which are the molasses formed when refining sugar. When cooked for a long time in iron woks it solidifies into cakes. This process improves shelf life. Grandma's reasoning was that "Jaggery is very rich and healthy and gives strength and blood". When I think of it now it makes sense, Jaggery is rich in IRON because of long continuous cooking in a crude iron wok.
UNHCR currently provides aluminium cooking pots and pans. So I was wondering whether providing iron pots and pans may help to combat anaemia. This made me remember grandma as well - who is no longer with us.

I discussed some of my thoughts on this, with a colleague at WEP who requested confirmation through the literature or experience that the use of iron pots in cooking could have a siguificant effect on haemoglobin levels of women and children. Through further networking we discovered that UNICEF have been involved in a study in Ethiopia which found that cooking with iron pots resulted in an equivalent improvement in iron status to that achieved with iron supplementation. We have asked around among our colleagues and found that there is not much published information on this phenomenon.

A number of us feel that it would be a good idea to run a pilot study to see whether cooking in iron pots and pans does actually affect the iron status of a test group. Of course we need to carefully think through the methodology before we can formalise such a trial. However, if we can reduce anaemia prevalence by replacing the aluminium pots currently supplied, with iron pots --- well maybe I'll start to take other things Grandma said a little more seriously.

    Yours, etc,
    Rita Bhatia, UNHCR

Nappies !!!



The UN official was back as usual to collect the "mortality figures". I gazed into the therapeutic feeding tents as he approached - toddler's bodies, wet and naked lined up side by side. Those strong enough, fingered faecal fluid off their neighbour's body; others, too weak to lift their heads, lay half drowning in pools of diarrhoea welling unnoticed on the uneven surface of the groundsheets.

It was Day 8 at the Centre for Unaccompanied Rwandan Children, Katale Refugee Camp, Zaire, July 1994.

Overcome by a surreal dementia, I turned to our unsuspecting visitor and verbally blasted him; "Look at these kids - they're dying overnight of hypothermia because they are wet! We cannot control cross infection because we cannot contain this diarrhoea. We can't keep track of the body count every morning there's 600 children under five years here now and truckloads arrive every day. Can you find us 15,000 disposable nappies to get us through this week and then we'll talk statistics
The utterance of those very words sent shivers down my spine...disposable nappies - so culturally alien, so environmentally unsound. The Rwandan (Centre for Unaccompanied Children) CUC Co-ordinator in desperation, endorsed the request.

A consignment of nappies arrived the very next day. A quick demonstration and each tent mother was adept and delighted at the prospect of being able to cope with her charge of thirty or so children.

The following morning, the children were still warm, huddled together. Upper body and clothing had remained mostly dry.

The mortality rate approximately halved overnight, levelled out over the next two weeks, then began its decline.

As anticipated, problems arose:
  • Nappy disposal (eventually collected by hygiene team and buried in pits);
  • Skin excoriation;
  • Tent mothers reluctance to revert back to traditional methods once feeding centres were established.
Feedback was recorded from a general staff meeting on
the 'short term'nappy episode; firstly, the staff felt able to cope better as they could concentrate on other aspects of care; secondly they felt the children were more comfortable and drier.

My questions are:
Did the nappies really work? - or were we simply witnessing the turning point of an epidemic curve? Experiential evidence suggests the former.

Considering the pros and cons - is there a case for 'starter pack' disposable nappy supplies in phase one emergency kits to reducecross infection and control body temperature?

This situation may well be unique given the volume of unaccompanied children and initial dearth of available healthy carers at that time.

Any thoughts, ideas or similar experiences to share?

    Yours, etc,
    Maggs Mac Guinness.
Dear reader,

This is yet another way you can get involved, and for those of you who are up to your eyes, with your sleeves rolled up, probably the simplest. The letters section is the 'anything goes' part of the newsletter. If you have useful tips, or want to air specific frustrations we want to hear about them.

You can also share your impressions, opinions, scepticism or reservations about much broader issues to do with emergencies. You can comment on this issue's contributions: support or refute impressions or findings based on your own experience. Remember do let us know your area of work, and if you want a prompt response, a contact address is useful. Now you know the score so post, phone, fax, E-mail, a grubby postcard or note in a floating bottle will do.

Looking forward to hearing from you,
    The editors

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