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Monday, September 2, 2013

The Mysteries of Malnutrition Management

On a bright and sunny morning I awoke excited for my first Growth Monitoring Outreach. It was a short walk to the neighbouring community of Majengo where we found many smiling faces (and a few wary ones too!) waiting to greet us. The concept of “weighing babies” seemed like fun but the importance of what we were doing started to unravel.

Malnutrition can be defined as “a state in which the physical function of an individual is impaired to the point where he/she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work, and resisting and recovering from disease” (The Sphere Project, 2004). In Kenya, the national figure for acute malnutrition of children under the age of 5 is estimated at 6% with huge variation in the different regions of the country ranging up to 20% or even higher (UNICEF, 2006). 

Under nutrition can be identified by assessing the individual’s nutritional status however this would involve investigating the availability and utilization of nutrients at the cellular level. Out in the field this becomes impractical so we rely of proxy indicators of nutritional status primarily Anthropometry (measurements of weight, height etc.) and recognition of clinical signs (oedema, skin pigmentation).

During the growth monitoring outreach we measured the child’s weight on a hanging scale and compare this to a Weight for Age chart on their Health Card. This allows us to graph their growth against a reference population, if they fall below the normal range the child is identified as underweight. We also check for immunization status and flag children who require follow up.
In total we weighed 54 children, including a set of 2 month year old twins and a little boy petrified on the Muzungu (white person)- I couldn’t look twice at him without him bursting into tears and running in the opposite direction! At the conclusion of the outreach two children were identified as underweight.
The question was what happens now? I sat down with Community Health Worker (CHW) and Pharmacist, Diego at Shimoni Dispensary to find out.
In the community, CHWs screen children using anthropometric measurements (e.g. weight, mean upper arm circumference) and the presence of oedema. Underweight or children displaying signs of oedema are referred to the nearest health facility for further investigation. A thorough assessment including questions about breast feeding status, diet and appetite is completed by a nurse or health worker and then an official diagnosis of malnutrition is made. The mother is also checked for signs of malnutrition and treated accordingly.

Further reading of the Kenya Guideline for Integrated Management of Acute Malnutrition
revealed that children can have a combination of both acute and chronic malnutrition. Acute malnutrition can be categorized into Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM), determined by the patient’s degree of wasting and certain criteria (eg. Comparison to WHO height for weight charts, mean upper arm circumference and level of oedema). All cases of bi-lateral oedema are categorized as SAM. SAM is further classified into two categories: Marasmus and Kwashiorkor. Patients may present with a combination, known as Marasmic Kwashiorkor.

Common signs and symptoms of Marasmus  include:
Severe weight loss and wasting, Ribs prominent, Limbs emaciated,Muscle wasting, May have good appetite, With correct treatment, good prognosis

For Kwashiorkor: Bi-lateral oedema and fluid accumulation, Loss of appetite, Brittle thinning hair, Hair colour change, Apathetic and irritable, Face may seem swollen, High risk of death

Chronic malnutrition is determined by a patient’s degree of stunting, i.e. when a child has not reached his or her expected height for a given age.

The management of acute malnutrition involves two basic objectives:

1) To prevent malnutrition by early identification, public health interventions and nutrition

2) To treat acute malnutrition to reduce associated morbidity and mortality.
(Ministry of Medical Services, 2009)

Diego explained at the Shimoni Dispensary all children under the age of 5 are given Mix Me a vitamin and mineral supplement to be added food as a preventative measure.

For children identified as moderately outpatient management involves food supplementation with Ready to Use Therapeutic Food (Plumpy Sup) and weekly monitoring.

Uncomplicated cases of severe malnutrition - patients who have a good appetite; are free from medical complications; and do not have moderate/severe oedema - can be treated with routine drugs (e.g. Antibiotics, deworming, vaccinations, Vitamin A supplementation) and the relevant quantity of ready to use therapeutic food (Plumpy Nut) at home. Families attend the dispensary for monitoring and to replenish therapeutic food supply, parents are encouraged to return empty packets to improve compliance. Further follow up is made at the home by the community health worker involving nutrition and health education. Children who have a poor appetite and present with complications such as oedema, hypothermia, fever, weakness or fitting must immediately be referred to an inpatient facility for further management.
Malnutrition is an important public health issue particularly for children under five years old who have a significantly higher risk of mortality and morbidity than well nourished children. We are happy to work with our partners, The Community Health Workers to help identify and prevent malnutrition through regular monitoring at the monthly Growth Monitoring outreaches.