Ambulatory treatment of severe malnutrition in Afghanistan

By Emmanuelle Lurqin

Emmanuelle is a paediatric nurse and since 2000, has worked with MSF Belgium on nutrition programmes in Angola, Burundi, and Afghanistan. She is currently working with MSF Belgium in the Ivory Coast.

During 2002, the author spent nine months in Faryab province, Afghanistan working as a nurse with MSF Belgium on the nutrition programme. This article describes her experiences in ambulatory care of severely malnourished children.

Faryab province is in a remote and poor area in the north of Afghanistan. There is little infrastructure, a high risk of disease outbreaks such as cholera and measles, and malnutrition is endemic. Communities have limited access to health care and education. MSF has been present in the province since May 1997, with programmes focused mainly on primary health care, nutritional interventions and responding to medical emergencies.

Malnourished infant with mother wearing burka

Following many years of war and more than three years of drought, Afghanistan was facing a food crisis situation. According to a WFP food security assessment carried out in July 20011, Faryab was one of the worst affected provinces of the country. A number of evaluations2 demonstrated that the food security of the population was extremely weak, and that there was extensive malnutrition as well as outbreaks of scurvy. Impoverished families had lost their land. Families who had land could not cultivate it because they had no seeds or they had lost their animals. A lot of cattle died during the drought. The quantity and quality of food aid distributed in the province was inadequate and vulnerable people in remote areas were not being reached.

The population used different mechanisms to cope with the situation. Some families sold personal belongings, including livestock and land, in order to get money to buy food. Some families even had to commit their daughter to marriage at an earlier age than usual in order to secure income. Many families resorted to loans from the wealthy while many men moved to towns or to Iran in order to find employment.

At the time of writing this article (January, 2003), the food situation remained precarious and the political and security situation unstable. MSF were operating five feeding centres in the province with an average of 2,200 beneficiaries (moderately and severely malnourished children and pregnant/lactating women).

Rationale for ATFC

A number of constraints made the implementation of a conventional 24-hour therapeutic feeding programme problematic in Faryab province:

More recently, there has been much discussion in the literature about community based therapeutic feeding programmes for treating severely malnourished children. Potential advantages of this approach are that it allows a decentralised programme thereby ensuring better coverage, it increases accessibility and acceptability and does not undermine family units. However, intensive medical/nutritional care and monitoring are much more difficult in outpatient treatment. Furthermore, individually tailored dietary regimes are impractical. Also, individually tailored dietary regimes cannot be employed.

Given the constraints of a 24 hour therapeutic feeding programme, and bearing in mind the advantages and limitations of community-based care, MSF opted to implement an Ambulatory Therapeutic Feeding Centre (ATFC).

Ambulatory care approach

This ATFC approach in Faryab involved malnourished children attending a feeding centre on a weekly basis. The feeding centres in Faryab province enrolled both moderately (supplementary feeding) and severely malnourished children. Admission criteria were based on weight-for-height (W/H), mid-upper arm circumference (MUAC), presence of oedema, or children transferred from the supplementary feeding programme. All malnourished children under 130 cm were eligible for admission.

Medical treatment

A complete physical examination, including a health and nutrition history, was undertaken for each child. Where possible, physical examination by a doctor was carried out weekly. Systematic treatment was administered according to standardised protocols, and any additional diagnosis individually managed. All children received measles vaccination.

Nutritional treatment

Nutritional treatment was based on "ready-touse therapeutic foods"(RUTFs) -Plumpy'nut and BP100. The quantity of RUTFs supplied per week varied, and was based on providing each child with 200 Kcal/kg/day. In addition, a supporting family ration was given to the mothers, to supplement - rather than substitute - the general food distribution. This comprised 6 kg of wheat per week, and provided an average 471 Kcal/person/day (based on a six person family). For infants under 60cm in length who were admitted to the ATFC, a support ration was given to the mother. This comprised 2.3 kg of premix (400g oil, 100g sugar, 1.8 kg corn soya blend), corresponding to 1540Kcal/woman/day.

Follow-up

After the medical consultation, the children remained as long as possible with their mother in the "TFC room". In general, the mothers were able to stay for 4 hours, during which time the nurse performed a number of tasks:

Health education

The health educator attempted to ensure the carer correctly understood the advised diet and importance of the treatment, and tackled health education issues (breastfeeding, complementary feeding practices, basic hygiene rules and main diseases).

Severely malnourished child with mother

Programme review

For the period January to October 2002, clinical records for 635 severely malnourished children were analysed and a review performed using traditional TFC indicators. As this type of programme is relatively new and has not been implemented in many places, it is difficult to compare results with a 'norm'. However, it is considered worth sharing findings from this programme, despite difficulties with their interpretation.

Nearly half of children were admitted under weight for height criteria (see table 1), and the female: male sex ratio was 1.19. Most of the new admissions were children with heights between 60-85 cm, corresponding to 6 to 18 months (see table 2). This age profile suggests that poor breast-feeding and complementary feeding practices were significant factors in the presenting cases of malnutrition. In our experience, many mothers continued exclusive breastfeeding for longer than six months (sometimes until 2 years of age).

 

Outcome indicators

In terms of outcome, the mortality rate of 6% was slightly higher than the MSF target of less than 5% mortality for a 24-hour TFC (table 3). An increase in June and July (19.4% mortality in July), and decreases between August and the end of the year (from 7.6% to 2.2%), most likely reflected seasonal diarrhoeal patterns. Where possible, the local team investigated causes of death. The reasons for death most commonly given by mothers were fever, diarrhoea, vomiting or cough

Defaulters

A child was defined as a "defaulter" after three consecutive absences from the centre. The high default rate in the programme (23.8%) was close to the MSF 'alarming' value for a 24-hour TFC (target <25%). In an attempt to identify reasons for defaulting, community follow-up of 29 defaulters by the nutritional team identified the following reasons, as reported by the mother:

As some of the children identified as defaulters will undoubtedly have died, the 6% mortality rate is likely an underestimate.

Weight gain and length of stay

Average weight gain in the programme was 6.1g/kg/day and the mean length of stay was 57 days, with little monthly variation. While these figures compare unfavourably with traditional TFC norms (target weight gains: 10- 20g/kg/d, target length of stay: < 30 days), results really need to be compared with other similar experiences and, ideally, with norms developed specifically for this type of programme.

Programme constraints

A number of factors may have adversely affected programme performance:

Lessons learned

The ideal strategy for treatment of severe malnutrition would be inpatient care, followed by community-based care and home management. However, despite the constraints of the ambulatory approach in Faryab province, a number of positive aspects of this strategy emerged. The programme was well accepted by mothers who were motivated to come, partly because their child received a full medical examination. Interest in the health education component seemed to increase, with mothers agreeing to stay longer to receive advice. RUTF was well accepted by the children. Also, children began to respond more quickly, both medically and in terms of weight gain, following the introduction of more systematic medical examination by doctors at the end of July 2002.

Through the course of the programme, some key lessons were learned which may help to improve future programming outcomes:

Outstanding issues

There are a number of outstanding issues that necessitate further research.

Finally, analysis of outcomes, including programme coverage, is essential for evaluating programme impact. However, to truly analyse efficacy of the ambulatory programme, further research is needed. This will require a collation and analysis of experiences in other contexts in order to refine the strategy and identify 'norms' for programme performance.

For further information, contact Sophie Baquet, Nutritionist, MSF B at email: sophie.baquet@msf.be

Show footnotes

1WFP Food security assessment, Vulnerability Assessment and Mapping Unit, July 2001

2Nutritional survey in Qaisar and Almar districts, Faryab province, Northern Afghanistan, MSF-B, August 2001; Nutritional survey in Qaisar and Almar districts, Faryab province, Northern Afghanistan, MSF-B, July 2002; Vulnerability assessment in Northern Afghanistan, Faryab province and Sar-I-Pol, Epicentre/MSF-B, January 2002; Field visit report Afghanistan, Sophie Baquet, MSF-B, March 2002. Field article

3RUTFs are not intended for initial treatment and are not indicated for use in young infants

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Reference this page

Emmanuelle Lurqin (2003). Ambulatory treatment of severe malnutrition in Afghanistan. Field Exchange 19, July 2003. p13. www.ennonline.net/fex/19/ambulatory