Reducing cases of chronic malnutrition
April 2013 - Tandiwe has the height of a four-year-old, but her mother insists she is seven. “Other children in the village who were born at the same time are now in grade two,” says her mother, who has neither a birth certificate nor a health card for Tandiwe.
The mother of four, Maida, 27, is waiting at the crowded Neshuro District Hospital in Masvingo district, trying to soothe Tandiwe while also nursing her other child, a 14-month-old baby.
Maida says she was aware of the importance of exclusive breastfeeding for six months after birth, but Tandiwe was sickly from birth and was not interested in solid food until the age of one. “She now eats sadza (maize porridge) and milk, but she doesn’t like vegetables. She is always coughing a lot. I’ve tried the clinics and faith healers, but I do not know what is wrong with her.” Tandiwe still has a bad cough; her hair is thinning and her stomach is swollen, possibly from worms. She looks petrified as she stands alone for a few minutes without her mother while her height is measured by the nurse.
Maida says she is struggling to bring up her four children, but Tandiwe is the only one who is “growing so slowly”. “We have a plot of maize and sorghum, but it has dried up.” She and her husband support their family by working on other people’s plots in exchange for food.
The district nursing officer for Prevention of Mother to Child Transmission (PMTCT), Restina Virukai, suggests that Tandiwe looks like she could be HIV positive. Maida (whose full name is not used to protect her privacy) tested HIV negative while she was pregnant with her. However, this might have been in the “window” period. It is possible she is HIV positive and has passed the HIV virus on to Tandiwe, who has never been tested.
Although her medical condition is unclear, Tandiwe suffers from chronic malnutrition and is now stunted. “Normally stunted growth is assessed in children under five years; it is the window of opportunity for intervention,” points out UNICEF officer for nutrition, Fitsum Assefa. “Tandiwe’s mother should have received information on how and when to introduce solids; maybe she is malnourished due to lack of resources or taboos. But as the other baby is thriving, it seems more probable that Tandiwe has an underlying condition which has caused the stunting.”
“Stunting is caused by persistent malnutrition in early childhood,” explains Assefa. “The child grows at a slower rate than a normal child over a period of time. To prevent stunting improvement must occur during the time the child is “actively stunting”; during the first two years of life. Intrauterine growth retardation can also occur in infants whose mothers are unwell or malnourished.”
Although the stunting rate in Zimbabwe is still lower than in other sub-Saharan African countries, it has increased over the past 15 years by nearly 40 per cent. Today, one in every three Zimbabwean children suffers from chronic malnutrition or stunting. Stunting is likely to contribute to more than 12,000 child deaths each year. Moreover, there are huge variations in rates of malnutrition between districts, affecting more rural than urban areas. It is also more common in boys than girls and, not surprisingly, children born into poor families are more likely to be susceptible to stunting.
Assefa points out that there are many causes for the high rates of malnutrition in Zimbabwean children. These include “poor feeding practices for infants and young children in the first two years of life, specifically low rates of exclusive breastfeeding (less than six per cent of infants are exclusively breastfed in Zimbabwe), poor quality and timing of complementary feeding, poor sanitation causing diarrhoea, worms and ingested bacteria causing poor absorption of nutrients, even without diarrhoea and other symptoms of illness.”
In contrast, acute malnutrition has remained low over time. Dr Itai Matibri of Neshuro District Hospital says most of the acute malnutrition cases are related to HIV and AIDS or other serious illnesses. Estimates in Zimbabwe suggest that up to 70 per cent of all admissions for treatment of severe acute malnutrition may be HIV positive cases.
Twelve-year-old Mercy Gumbo is admitted to the hospital emaciated and weak. She has just been diagnosed with TB. The nurse gives her “plumpy nut”, which is a high energy paste containing peanut butter, milk powder, oil, sugar, minerals, vitamins and protein mix, which is one of the various ready to use therapeutic foods. It can be used easily in the community to treat severely malnourished children, because it does not need to be cooked and can be stored at room temperature for a long time. Mercy is benefitting from the plumpy nut paste before starting a course of TB drugs. Mercy’s aunt, Ruth Muhwadzarira, keeps an anxious vigil. She explains that Mercy’s parents and younger sister have recently died of TB.
Micronutrient malnutrition is another type of malnutrition, but less visible. It weakens the immune system and mental development and is potentially fatal. Particularly worrying are the high levels of anaemia. More than half of children aged 6-59 months and nearly half of pregnant women suffer from anaemia in Zimbabwe.
All types of malnutrition in Zimbabwe are preventable. Global evidence shows that exclusive breastfeeding can reduce chronic malnutrition at 36 months - the cut-off age for irreversible stunting - by 36 per cent, and reduce mortality by 25 per cent. The promotion of improved complementary feeding practices alone could reduce chronic malnutrition by more than 15 per cent.
To tackle these rising levels of malnutrition, UNICEF supports a variety of interventions, including a national programme which addresses stunting. UNICEF also supports training at all levels, including village health workers, to ensure good infant and young child feeding practices, and to promote good sanitation. Furthermore, UNICEF supports micronutrient supplementation, food fortification and treatment for severe undernutrition. The plumpy nut that Mercy was given is especially effective and can be administered in the community. However, treatment for Tandiwe to make a full recovery has come too late.