Treating severe malnutrition in nonemergency situations: Experiences from Malawi and Guinea

By Dr. Eva Grabosch, M.Sc, CHDC

Malnourished boy recovering in the nutrition unit of the Teresian Sisters Hospital, Alinafe, Malawi

Dr. Eva Grabosch is a specialist in paediatrics. Following her experiences working in an acute emergency situation in Ethiopia in 1984/5, she worked as a health specialist in the Lilongwe Central Hospital in Malawi between 1994 and 1998 and in the Regional Health Office in Kankan, Guinea, from 1998 to 2000.

The article below highlights the difficulties of providing effective treatment for severe malnutrition in non-emergency situations within local health structures based on experiences in Malawi and Guinea. It also identifies sustainable strategies that were effective in improving treatment of the severely malnourished after external agency support had been withdrawn. Programmes for treating malnourished children in developing countries that are supported by donors or international humanitarian agencies are frequently not sustainable in the long-term. A point inevitably comes when external agency resources are withdrawn. Unless provision has been made for local funding and capacity building there may be a marked decline in the adequacy of treatment once external agency resources and support disappear. This may be especially marked following emergency programmes involving staff from international agencies.

Field Exchange would like to point out that the activities described in this article do not represent best practice and that recipes are not tested (see post-script by Dr Ann Hill and box). (Editor)

Malnutrition in Malawi and Guinea

Compared to Ethiopia in 1985, where there was an acute emergency caused by war and drought, the situation in Malawi and Guinea was comparatively stable although health and nutritional conditions were extremely poor (see table 1).

Survey data showed that malnutrition was prevalent in both countries. In Malawi, 7% of the children under five suffered from global acute malnutrition (Wt/Ht z score < 2) and 48% from chronic malnutrition (Ht/age z score < 2). In Upper Guinea, a region in Northern Guinea, the figures were 17% and 40% respectively². In absolute figures this meant that during this time, there were more than 80,000 children in Malawi and about 25,000 children in Upper Guinea affected by acute malnutrition.

In Lilongwe Central Hospital in Malawi it was common for approximately 60 out of the 200 beds available for children to be occupied by cases of severe malnutrition. Malnutrition, and not malaria, was the leading cause of death. Despite the high prevalence of malnutrition in Upper Guinea, malnourished children were rarely admitted with this diagnosis to the five hospitals of the region. However, a survey at the Regional Hospital of Kankan showed that up to 20% of the admitted children actually had underlying signs of acute malnutrition.

Malnourished children in Malawi and in Guinea were predominantly aged between nine months and three years. Risk factors for children admitted with severe malnutrition were poverty, poor weaning diets, maternal illness and early weaning due to new pregnancy of the mother.

Challenges to nutritional rehabilitation

When I first began working in Malawi and Guinea, nutrition programmes in both countries (which were initially supported by several donors) had almost collapsed. In Malawi, the hospital received some irregular milk supplies from the World Food Programme (WFP). In Guinea, malnourished children received no special foods at all in the hospital but advice was given to feed the children with protein rich foods. They did receive some medical treatment (antibiotics, vitamins, intravenous infusions). However, in both countries the majority of mothers were not able to afford milk products or other food containing animal proteins. Medical personnel were poorly motivated and discouraged because children with malnutrition either died or absconded. In Malawi, hospital staff were scarce and over worked. Therefore, it was common practice not to include malnourished children in daily rounds. Tube feeding was only carried out in severe cases and mothers generally did not accept this practice.

In order to establish effective nutrition rehabilitation programmes, it was recognised that it was necessary to adapt the programme to local conditions. The main challenges in both countries were lack of food supply, low motivation, and poor education of staff. Programme organisation and supervision proved key factors in improving outcomes.

Food supply

The first challenge was to establish a regular supply of nutritious food. In both countries it was not possible to rely on families to buy milk based foods. Mothers may have been willing to do so in the initial phase of rehabilitation, but the great majority of them could not afford to do so for the whole initial phase. With about 60 malnourished children starving in the hospital in Malawi, I approached several donor organisations. I learnt that resourcing programmes to treat malnutrition in a non-emergency situation did not fit easily into donor funding mechanisms, i.e. they either wanted to fund treatment programmes for malnutrition in the context of an emergency programme or preventive food security measures as part of a development programme. The hospital administration in both countries felt responsible for the medical care of severely malnourished children - but not for their nutrition. These children were therefore falling through the net.

In Malawi, WFP projects had been phased out gradually although they still irregularly supplied some milk powder, oil, cereals, and beans to the hospital. After 20 years WFP wanted to invest in preventive measures as " the old programme had not changed the situation and was not sustainable".

In Guinea, an NGO had supplied food for a nutrition rehabilitation programme some years ago. After the end of the NGO engagement, the programme had collapsed due to lack of basic foods.

Both experiences demonstrated that donor provision of therapeutic foods was not a sustainable approach to the treatment of severe malnutrition in children.

After intensive negotiations and lobbying, hospital administrations in both countries acknowledged that food was an essential part of a nutrition rehabilitation programme and therefore had to be given equal importance to the provision of drugs. Drugs were supplied free to patients in Malawi and in Guinea - payment for them was included in the admission fees. Both hospitals therefore agreed to supply food to children with severe malnutrition if the parents could not afford to pay for them. A fixed budget for this was allocated to the programme on a monthly basis. The total amount for this was small and did not allow for the purchase of F75 or F100. In Malawi, milk powder, oil and corn flour could be purchased by bulk order. In Kankan (Guinea), the price for milk powder exceeded the available resources. Thus, an alternative liquid diet based on locally available peanuts (peanut milk) was introduced.

100 ml of peanut milk contains 82 kcal

The peanut milk was well tolerated. Although the number of children evaluated is small (ten children), it was evident that most children showed a good weight gain under this regime (see table 2). Restoration of appetite was prompt. Side effects were not seen and existing diarrhoea came to a rapid end. Unfortunately our project was terminated at the end of 2000, for reasons outside the ambit of this article, disrupting the evaluation such that no further data are available to date.

World fact book 2001¹

Training and motivation of staff

The second challenge was to convince staff that malnutrition is treatable in a high percentage of cases, that cure rates can be increased, and that relapses need not be the norm.

Staff in both hospitals received refresher training in the management of malnutrition. Basic knowledge was very low, especially in Guinea. However, we soon realised that theoretical knowledge alone did not have the desired impact and that on the job training had a much higher impact on overall performance. Motivation seemed to be strongly dependent on the experience of having successfully treated malnutrition. Thus a precondition for the motivation of staff was the employment of at least one experienced staff member to start and supervise the new programme. The first child who smiled after being cured from Kwashiorkor soon convinced the rest of the team.

Organisation and supervision

In both countries, organisation and supervision of the nutrition programme was not easy. The necessary food supplies had to be procured, some additional staff were employed, and treatment guidelines were elaborated.

Supervision of food intake and clinical practices by medical and paramedical staff was very important. The intake was recorded on special surveillance forms at each feed. Clinical examination of nonresponders was carried out promptly and frequently revealed treatable infections. During feeding, mothers and children were sitting in a circle. This facilitated supervision and helped newcomer parents to learn from the more experienced mothers. If the child's intake was not sufficient, the remaining feeds were given by nasogastric tube. Mothers themselves administered the feeds via the tubes.

In Guinea the child was weighed every second day and medical examination performed during the daily ward rounds. Due to scarcity of staff, ward rounds could only be carried out three times a week in Malawi. Opportunistic education of mothers was an integral part of each contact with staff. Supervision of feeding by paramedical staff was an occasion to talk about nutrients, the causes of malnutrition, and the need for frequent, adequate feeds. During ward rounds, the mothers learned how to treat diarrhoea and vomiting, or how to suspect infections etc. Mothers participated in the preparation of food and thus learned how to prepare the food.

Adaptation of guidelines

Adaptation of the nutrition programme generated many technical problems to solve. Given the scarcity of resources, malnutrition treatment guidelines had to be adapted to the local situation.

According to WHO recommendations severe malnutrition should be diagnosed using weight for height measurements and indexes^3,4. Although the local authorities in both Malawi and Guinea reinforced these recommendations, measuring equipment was not available in many of the health centres, and staff were not using it where it was present. There were no means to supply the necessary equipment or to motivate all staff to use it. In cooperation with the local health authorities it was therefore decided to use the weight/age ratio at health centres for detection of malnutrition and to follow up at therapeutic feeding centres using the weight for height index. Entry criteria for the therapeutic feeding programme was set at less than 70% of W/Age in Malawi and below the third percentile of the Road to Health Chart in Guinea.

WHO recommends using F75 milk based formula in the initial phase of rehabilitation of severe malnutrition. 3,4 However this commodity was neither affordable nor available. In Guinea, a peanut based liquid with added sugar was prepared as the initial therapeutic feed for phase one. This so-called 'peanut milk' contained sufficient protein and calories for the initial rehabilitation phase. Although the composition of amino acids was not optimal, it was felt that it was better to give this 'milk' than nothing at all or relying on locally available porridges, which would not be swallowed by many children in the initial rehabilitation phase. The peanut milk was easily digested and no side effects were observed. In Malawi, no local, affordable protein rich food was found. Therapeutic milk therefore had to be prepared from milk powder, oil, and sugar.

In the initial phase, the children received liquid food (milk or peanut based) only. Semi-solid porridges were given in phase 2 after restoration of appetite. This comprised corn / soybean or corn / peanut porridges given in increasing quantities to allow for catch up growth.

WHO recommends two-hourly feeds for all children with severe malnutrition in the initial phase in order to avoid hypoglycaemia. Unfortunately in both countries, it was difficult to organise two-hourly preparation of food, especially at night. Lack of staff, no electricity in the wards, and sleeping mothers were some of the reasons. It was therefore decided to give 6-8 feeds daily between 6 a.m. and 10 p.m. In the meantime, continuation of breast-feeding with frequent feeds, especially at night-time, was recommended.

There were also problems in supplying the recommended vitamins and minerals. ReSoMal was not available, and the same held true for zinc and copper. Only folic acid and iron tablets were available. Bananas were recommended to mothers as a source of potassium.

After nasogastric tubes were purchased with support of donor organisations, tube feeding was introduced. It was noticed that mothers accepted tubes, when they saw other children recovering whilst on tube feeding.

Conclusion

Malnutrition has to be treated with both food and drugs. It is therefore necessary to regard provision of nutrients as essential for recovery, and to organise and ensure nutrient supply in the same way as the supply of essential drugs. It was possible, and necessary, to convince the hospital administrations in Guinea and in Malawi of this and to get them to budget for the required foods. This guaranteed the sustainability of the nutrition rehabilitation programmes.

The budget in Guinea was kept to a minimum through the introduction of a rehabilitation scheme using only locally available foods. The regime based on peanuts was well tolerated. However, the number of children treated with this new regime was too small to allow for definitive conclusion about efficacy. A further evaluation of this treatment is highly recommended.

In Malawi, despite the necessary adaptations of the WHO recommendations, it was possible to reduce the PEM associated mortality, amongst the 608 children treated at Lilongwe Central Hospital, from 30 % in 1995 to 21 % in 1997⁵. Clinical and paramedical supervision of the nutrition rehabilitation seems to have been an important precondition for the success of the programmes in both countries. The remaining high mortality may have been partly due to the elevated HIV/AIDS prevalence in Malawi⁶.

The results would have been undoubtedly better if WHO recommendations could have been followed. But, is it not better to have a sparrow in the hand than a dove on the roof? (German proverb)

For further information, contact: Dr. Eva Grabosch (M.Sc. CHDC), K¸hlenbergstr. 34, 97078 W¸rzburg, Germany

View the postscript that this article relates to

¹CIA World fact book 2001, http://www.odci.gov/cia/publications/factbook/index.html

²M. de Onis C, Monteiro J AkrÈÇ and Clugston G. The worldwide magnitude of protein-energy malnutrition: an overview from the WHO Global Database on Child Growth

³World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers, Geneva 1999, WHO Library Cataloguing in Publication Data, ISBN 92 4 154511 9 (NLM Classification: WD 101)

⁴World Health Organization. Guiding principles for feeding infants and young children during emergencies, Geneva, World Health Organization, 2000

⁵Republic of Malawi, Annual report 1997, Paediatric Department of Lilongwe Central Hospital, 1998

⁶Kessler L et al (2000). The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi: Annals of Tropical Paediatrics, vol 20, pp 50-56