Essential Nutrition Interventions in Kayin State: Bridging communities and hospitals

Integrated management of acute malnutrition (IMAM)

Tin Aung
IYCS Session
UNICEF Myanmar/ 2020
18 December 2020

Acute Malnutrition is life threatening for our children under-five years of age

Under nutrition is strongly associated with mortality in children under-five years of age. Wasting (severe loss of muscle and body fat) is an acute form of malnutrition,  where children are having dangerously low weight for a given height resulting from recent stress in the child’s body because of illness, infection or severe food consumption shortage and or inappropriate feeding practices which make children weaker and prone to diseases, such as diarrhoea or respiratory infection. It is assessed by measuring weight-for-height, mid-upper arm circumference (MUAC) that measure fat loss or the presence of oedema. 
Myanmar’s Demographic and Health Survey of 2015-16 revealed that seven percent of children in Myanmar aged under-five years were classified with acute malnutrition but with large variation across different state and regions in Myanmar. In Kayin State, the prevalence of wasting is six percent among children under-five years old.

Despite strong macroeconomic growth and poverty reduction over the past decade across the country, Kayin State continues to suffer from a high prevalence of maternal and child undernutrition. More than one-third of under five years old children in Kayin State are classified as stunting, characterised by low height for age and will not reach their full potential because of delayed growth and development.  (Myanmar Micronutrient and Food Consumption Survey Interim Report, 2017 – 2018).

MUAC measurements
UNICEF Myanmar/ 2020
A child at the Myaing Gyi Ngu Station Hospital having her mid-upper arm circumference (MUAC) measured.

Essential Nutrition Intervention to fight acute malnutrition 

In Kayin State, children with acute malnutrition were only treated at the Nutrition Unit of Hpa-An General Hospital, until 2018. Since then, integrated management of acute malnutrition (IMAM) interventions started around the state and children could get treatment at other facilities at community level. 
In 2019, 36 children under-five with severe acute malnutrition (SAM) with other medical complications were admitted to in-patient programme (ITP) in Kayin State. A total of 86 SAM cases were treated at the Outpatient Treatment Programme (OTP). 
In addition, 1,158 children under five were had moderate acute malnutrition (MAM). Thus, a total of 2,070 moderate acute malnutrition cases were treated in the Supplementary Feeding Programme (SFP). Of these, 1,692 children were cured. By the end of 2019, 147 children were continuing treatment. 

Teamwork and collaboration save lives of children with acute malnutrition

The Hpa-An General Hospital Children’s Ward opened its Nutrition Unit in 2015 to provide treatment for acute malnutrition among children under-five years old. Since 2018 this service has been developed into the In-patient Treatment Programme and integrated into basic health services.

Four-year-old Aye Win Ko was admitted to the Children’s Ward of Hpa-An General Hospital in May 2019, diagnosed with pneumonia and acute malnutrition. He came with high fever, chest-in-drawing and rapid breathing. While thin and lethargic, he had no appetite and had swelling on his feet and hands.

At that time Aye Win Ko’s mother, Ma Khin Pyawt, was working as a maid in Kha Lauk Name village near Hpa-An and had separated from her husband. Ma Khin Pyawt was poor and unable to care for and feed her son. Neighbours found the severely ill boy and brought him to the hospital where the senior paediatrician and nurses provided essential health care and therapeutic feeding, according to guidelines. “Fortunately, last year we set up a Nutrition Corner in our Children’s Ward together with nutrition supplies from UNICEF, such as oral rehydration solution and therapeutic milk products to treat severe malnutrition, and we are familiar with the use of therapeutic feeding of F-75 and F-100 for children with acute malnutrition,” explained Daw Kaythi, a nurse in the Children’s Ward. After spending two months in the hospital being treated for severe acute malnutrition with complications, little Aye Win Ko was discharged and referred back to Wah Su Rural Health Centre for continuous treatment with ready-to-use therapeutic food (RUTF) at home. “When Aye Win Ko was discharged from hospital, the Township Nutrition Focal Point recommended that I follow up and supervise the little boy’s ongoing programme of feeding with RUTF. I also held some counselling sessions with Aye Win Ko’s mother and her neighbours on how to better feed her. Three months later, the child had completely recovered,” reported Nang Lady Win, midwife from Wah Su Rural Health Centre. “This is a lifesaving example of how integrated management between hospitals and rural health centres can ensure effective care for a child with acute malnutrition,” added Daw Kaythi, the nurse from Hpa-An General Hospital’s Children’s Ward. 


Finding children with acute malnutrition before it is too late through active case finding among children in displaced population

Kayin State has been experiencing long-running internal conflicts, which has led to population displacements, poverty, food insecurity, insecurity, loss of lands and income sources as well as diseases in an environment where health services are limited. Displacement can negatively affect children’s nutritional status and hamper access to essential health interventions. 

During September 2016, series of armed conflicts around Hlaingbwe Township, in Kayin State, sent nearly 6,000 people fleeing from their homes. Today about 3,500 people remains in the Myaing Gyi Ngu camp for internally displaced people (IDP). This long-term conflict has meant that many of the IDP has constrained in accessing regular health services. Today, regular health services are provided by Myaing Gyi Ngu Station Hospital and Rural Health Centres. However, challenges for access still exist, due to social and language barriers. The IDPs are still afraid of the Myanmar government and medical interventions such as injections in hospitals, so they are reluctant to come for treatment at hospital or health centres. Ethnic Karen people speaking local Karen language find that the health staff cannot understand them or communicate with them. Many IDPs in Myaing Gyi Ngu camp are vegetarians and they have limited access to their farms and food supplies due to the conflict. The prevalence of malnutrition among children aged under-five years in the camp is higher than in nearby villages. The health staff of Myaing Gyi Ngu Rural Health Centre regularly detect and monitor cases of acute malnutrition among children under-five years old, also among both pregnant and lactating women living in Myaing Gyi Ngu IDP camp. They also screen for acute malnutrition among the under-five years old children attending the Outpatient Clinic. 

Nan Shwe Yee is a 27-year-old mother living in and out of Myaing Gyi Ngu IDP camp with her three children. The family is poor and Nan Shwe Yee’s husband has left to find work outside the camp. With no job or income, Nan Shwe Yee totally depends on the kindness of well-wishers and neighbours for food. All her children are malnourished. Her youngest child, who has a cleft lip, is severely malnourished. The malnourished children were discovered by Daw Tha Zin, a Lady Health Visitor of Myaing Gyi Ngu Rural Health Centre during an active case finding activity, which is now part of the regular health services provided in the IDP camp. “At first the internally displaced people were afraid to come the clinic and so we had to try hard to reach them. We visited their houses to educate them about good health habits. Some IDPs ran away when they see us. They are really afraid to engage with government staff,” said Daw Thu Zar, a Lady Health Visitor. “When I attended the clinic, not only did they give me medicine and food packs for my children, but also some legumes and potatoes. I’m following the health staff instructions and bring my children regularly to the clinic,” explained Nan Shwe Yee. Since the start of the Integrated Management of Acute Malnutrition (IMAM) programme in July 2018, more than 30 children have been treated for acute malnutrition in Myaing Gyi Ngu IDP camp. 

Raising community awareness and engagement in nutrition
Raising community awareness on good practices for Infant and young child feeding is crucial for prevention of malnutrition among children under-five years old as well as among pregnant and lactating women (PLW). Education and counselling sessions on nutrition are now provided regularly at health centres in community settings. Since 2016, training on infant and young child feeding at the community has been provided in Kayin State. However, it is still challenging to build the knowledge and to improve child-feeding and caring practices. 

Supportive supervision on nutrition for health workers 
Supportive supervision is key to improving health staff performance. For this reason, the State Nutrition Team carries out regular field visits to health centres around the country to check records, registers and reports and to supervise and support the basic health staff, encouraging them to undertake regular nutrition services in their catchment areas. Standard checklists are used to assess performances and the on-the job training helps to improve the knowledge and capacity of the basic health staff. The integrated management of acute malnutrition (IMAM) links hospitals and basic health services and saves the lives of children like Aye Win Ko and San Mya Mya. The Japan National Committee for UNICEF generously supports UNICEF and its implementing partners, the Ministry of Health and Sports and State and Regional Health Departments to deliver these vital nutrition programmes.


Supportive supervision team of state health department nutrition team in Kayin State.
UNICEF Myanmar/ 2020
Supportive supervision team of state health department nutrition team in Kayin State.