Thursday, January 30, 2014

The Story of Shanita: Treating Malnutrition in Children Less Than Six Months

At Bugangari Health Center IV in rural, Southwestern Uganda, the Initiative to End Childhood Malnutrition (IECM) has run an outpatient therapeutic care (OTC) site since 2011. Bugangari is one of seven outreach sites IECM managed in 2013. The catchment population of Bugangari is similar to that of the entire Southwest region. According to the Ugandan Demographic Health Survey in 2011, the region has the second highest rates of severe and acute malnutrition in the country, second only to the Karamoja region, which is prone to drought and conflict.

In August, a two-month old severely malnourished infant named Shanita came in with her grandmother to the IECM outreach site in Bugangari. At 2.3 kg she was enrolled as an outpatient and started receiving infant formula since her mother had passed away. Over the next few weeks the IECM outreach nurses noticed that Shanita’s condition was not improving. The nurses took the time to explain to the grandmother, Shanita’s caretaker, the necessity of bringing the infant into Nyakibale hospital for inpatient therapeutic care (ITC). ITC is administered on a special malnutrition ward separated from other pediatric patients to avoid transmission of disease since malnourished patients have a depressed immune system. Without proper attention and close monitoring by clinical staff, Shanita’s condition would not improve. While convincing a caretaker to leave her village, family, and farms is difficult, Shanita’s grandmother agreed to travel 18 km to Nyakibale Hospital for inpatient care. She was transported back by IECM’s outreach team in their Rav4 for the forty-minute care ride back to Nyakibale hospital.

Within hours of being admitted to the malnutrition ward, the nurses and our Food and Nutrition Technical Assistance (FANTA) Nutrition Fellow discovered that Shanita’s grandmother was not able to properly prepare formula. In fact, why would she? All of her children and all of her grandchildren had been breastfeed. She was excessively diluting the formula that the IECM outreach team had been providing her on a weekly basis at Bugangari. After observing and teaching her how to prepare the milk, she was able to make it on her own. Over the next twenty days Shanita went from 2.4 kilograms to 3.18 kilograms and was discharged back to our outreach program at Bugangari. Until Shanita was able to start taking solid foods at six months, IECM was able to provide infant formula for her grandmother to prepare.

Without IECM, there would not have been out outpatient site where Shanita’s grandmother could access treatment close to home. Just as importantly, the program provided all outpatient and inpatient treatment free of charge. Without the program Shanita would never have received infant formula. And, with her mother deceased, she would have passed away silently in Bugangari.

IECM has transitioned to following Uganda’s national guidelines for the treatment of malnutrition, namely Integrated Management of Acute Malnutrition (IMAM). For those infants under six months who are not effectively breastfeeding, the guidelines encourage counseling for mothers. However, for those infants who do not have access to breast milk, the guidelines encourage the use of diluted F100 (high energy milk only available through inpatient therapeutic care), or infant formula. However, caretakers must purchase the infant formula, which is not provided free of charge like the F100, F75, and Ready-to-use-therapeutic-food (RUTF). Infant formula can cost approximately 32,000 Ugandan shillings per tin (approximately $13), and many of our caretakers report earnings of between 5,000 and 10,000 shillings per month (about $4). Without IECM, Shanita would never have survived. It is thanks to the generous funding that has made treatment and prevention of malnutrition possible in Bugangari and all of Rukungiri District.

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