Yona and Gracie

Every year an estimated 12 million children die before they reach their 5th birthday. Seven out of every ten of these deaths are due to diarrhea, pneumonia, measles, malaria and malnutrition. In developing countries an estimated 50 million children under the age of five are malnourished. At least 25% of the world’s pediatric population is undernourished. Malnutrition contributes to fifty-four percent of deaths in children 0 to 4 in developing countries and is most commonly seen between 6 months and 30 months. Malnourished children are more likely to have severe even fatal as well as just longer lasting infections. Malnourishment puts children at risk for delayed mental development, behavioral problems, school performance issues and poor employment. Even a small degree of iron deficiency anemia can affect learning.

Severely malnourished children admitted to hospital face a 30-50% case fatality rate. With appropriate treatment, this high death rate can be reduced to less than 5%.The difference in mortality rate is not due merely to the level of disease severity but is related to the level of care. Severe malnutrition is a medical emergency. Hypoglycemia, hypothermia and silent infection can quickly lead to death.Children with malnutrition are often identified as having either Kwashiorkor or Marasmus. Children with Kwashiorkor appear edematous and children with Marasmus appear starved and thin. Kwashiorkor malnutrition is thought to be caused by protein deficiency and Marasmus by energy or total calorie deficiency. Kwashiorkor is the word for the disease given by the Ga tribe in Ghana meaning “the sickness the older child gets when the next baby is born” and is associated with inadequate diet during the weaning period. An inadequate diet is rich in carbohydrates but poor in proteins. In Malawi children are often given only two meals a day; corn porridge for breakfast and then later a meal primarily of nshima a powdered corn flour boiled with water into dough that is served with a relish made from greens, onion and sometimes tomatoes. Fruit and ground nuts are sometimes also given.

There are ten essential steps in the management of malnutrition
    1. Treat/prevent hypoglycemia.
    2. Treat/prevent hypothermia
    3. Treat/prevent dehydration
    4. Correct electrolyte imbalance
    5. Treat/prevent infection
    6. Correct micronutrient deficiencies
    7. Start cautious feeding
    8. Achieve catch-up growth
    9. Provide sensory stimulation and emotional support
   10. Prepare for follow-up after recovery

With one nurse for 75 patients at Nkhoma Hospital in Malawi, it is impossible to monitor all the patients regularly during the night. It is up to the guardians to alert the nurses when there are problems. Children with severe malnutrition need to be kept warm and dry. Guardians may only bring a thin cotton cloth to the hospital. Children need to be fed day and night. The guardians are provided specially formulated milk F75 and F100. It is the guardians who must take responsibility for giving the children regular feeding throughout the night. These children are especially difficult to care for as they are apathetic, anorectic, withdrawn, irritable and generally miserable. Their appearance is often abhorrent; skin is sloughing and bleeding, bodies edematous and wasted, disfigured with loss of hair and sores. Corneal ulcerations, keratomalacia, corneal scarring and irreversible are common with vitamin A deficiency. Malnutrition leads to impairment of the immune system, impaired absorption of nutrients, increased catabolism, poor appetite, vomiting, diarrhea, vitamin deficiencies, impaired skin defenses and cardiac dysfunction. The causes of malnutrition are complex and involve social, economic, cultural, and political elements. Some of these include such things as maternal deprivation and abandonment, child abuse, food taboos, poor child rearing practices, misconception about the use of certain foods, inadequate feeding, improper food distribution within family members, overcrowding and unsanitary living conditions, weather patterns, post-harvest food losses due to bad storage, natural disasters such as drought and famine, and civil conflict. Yona’s 9 month old little sister Gracie finally got sick today. 

Gracie is the reason Yona is hospitalized with Kwashiorkor. When she was born, Yona was pushed off the breast. Since then Yona has eaten mostly starchy foods and little protein. Gracie is a little underweight as she is primarily receiving breast milk. Now Gracie is sick. It is not surprising in many ways since her last two weeks have been in our ward surrounded by sickness. She has spent a lot of time on the floor of the ward eating crumbs she dropped there. She and her mother have moved among our sickest patients with pneumonia, TB, meningitis and malaria. She has been watching the F 75 NG feeds, the daily pills, the deaths of children and the wails of their parents. She has witness episodes of vomiting, diarrhea, crying, screaming, moaning and tears. She has heard countless interview questions with countless parents as we admit over 25 new patients per day. Gracie has also seen her brother improve. When Yona first came to Nkhoma Hospital his eyes were so edematous they were swollen shut. She has seen it all and now she is entering the fray more personally as we stick her for a rapid malaria test, then draw blood for her hemoglobin, take her temperature and listen to her lungs. It is pneumonia and yes, her rapid malaria test is positive. She will need an IV for quinine. Hospitals are dangerous places to hang out!