Treating severely malnourished children at home
Bertha Muwoma feared the worst for her two-year-old son Brian. He had been in and out of hospital and this latest episode threatened to take him back yet again. Brian had a swollen stomach and limbs, clear signs of kwashiorkor, a severe type of protein deficiency malnutrition which, if untreated, can be life-threatening.
Her husband lives in South Africa and she is not sure when he will come back. Bertha has had this problem several times before. Brian is HIV-positive and has endured several bouts of malaria and severe diarrhoea. This time, Bertha looks confident as she cuddles Brian in her lap and lovingly spoon feeds him 'plumpy nut', the protein-rich peanut butter paste UNICEF procures to treat severely malnourished children. Brian loves it, which is helpful because she must give him the food every three hours, day and night. After one month of plumpy nut, the child then takes Likuni Phala, a supplementary porridge made of maize meal and soya, for a month.
Plumpy nut, manufactured locally in Malawi, has made the treatment of severe malnutrition much easier for families as it is administered at home. In a country where the nearest health centre could be up to 10km away, families find home treatment preferable, as it frees up their energies and time for other activities. It is also cheaper than the therapeutic milk which has to be administered in hospital under the supervision of a doctor. This is significant progress considering that malnutrition is widespread in Malawi and is one of the major causes of infant and child morbidity and mortality.
Wemah Mbalame is the nurse-incharge of the Mpemba Health Centre Nutrition Rehabilitation Unit in Malawi's commercial capital, Blantyre. She oversees Brian's progress and keeps an eye on other children in the area too. She believes that most severely malnourished children, as long as they are not undermined by HIV, are better treated at home.
“Plumpy nut is easy for the mothers to administer, the children like it, they are responding well and the mothers are able to stay at home, look after their other children, do their normal work and farm,” she says. “The mothers have even started bringing their malnourished children to the health centre before they get too serious ill. I think it is because they know that they can treat their children at home.”
Malnutrition is a big problem in Malawi, and has been since 1992 when the country suffered a devastating drought. Some 46% of children under five years are stunted, 21% are underweight and 4% are wasted. Micronutrient deficiencies are also widespread. About 60% of under-five children have vitamin A deficiencies and 48% of pregnant women suffer from iron-deficiency anaemia.
The reasons for the lack of progress are complex. A low level of maternal education and a lack of knowledge on good childcare practices, means children do not receive optimal nutrition and care. Even when mothers do know about the importance of a balanced diet, poverty is so widespread that many families cannot afford to diversify their diets. Natural disasters such as droughts and floods add to the problem of poverty, as do recurrent illnesses such as diarrhoea and malaria.
In recent years AIDS has undermined gains made in child survival. At least 50% of acute malnutrition is associated with HIV and AIDS; an estimated 102,000 children are living with HIV. Nurse Mbalame counsels parents or caregivers whose children she suspects have HIV. “Most of the mothers agree to HIV testing, but some of them first go home to ask their husbands.”
Malawi's national nutrition programme, supported by UNICEF, has preventive, treatment and monitoring components. It includes de-worming children under five years old, distributing micronutrient supplements (such as vitamin A), improving the care and treatment of malnourished children in hospitals and communities, and regularly monitoring the weight and height of under-five children.
The programme needs the dedication of nurses like Mbalame to succeed. She walks as far as 15km on steep, hilly dirt tracks to see how the malnourished children under her treatment are responding. She also sees the mother and child once a week at the health centre. Community health volunteers play an important role too, visiting families to identify malnourished children.
Through the nutrition education programme, mothers are taught to recognise symptoms, especially the swelling of hands and feet, a sure sign of oedema. Nutrition and hygiene are also an integral part of the programme. “I learnt how important it is to wash my hands with soap or ash after using the toilet and before cooking,” says Muwoma. “I use ash as I can't afford soap.”
The young mother also learnt about giving Brian a balanced diet and enough food. Yet it is not easy for Muwoma, who was orphaned as a child. She has no land to cultivate and does not know whether her husband has found a job yet. “Sometimes we eat three times a day, sometimes twice, depending on what is available,” she says.
Yet, despite her problems, Muwoma is looking ahead and is determined to do the best for her sons. “I would like to go back to school in the future. I dropped out in form 1 because I became pregnant. But right now, I need to earn money, so I have a job working as a domestic helper.”
She will receive only 2,500 kwacha (about US $16) per month, but will have food and shelter free. “I have already told the woman who has employed me that Brian will need a good diet as he has suffered from malnutrition,” she says.