December 5, 2012

In Yida refugee camp, South Sudan, teams from Médecins Sans Frontières/ Doctors Without Borders (MSF) have set up outpatient treatment sites for children suffering from malnutrition. In late-July, as child mortality increased considerably in the camp, MSF scaled up its activities to be able to treat the refugees, many of whom were arriving from Sudan in a very weak condition. From the end of July to mid-November, MSF treated more than 1,680 children suffering from malnutrition as outpatients, while 443 malnourished children received hospital care. An MSF team makes weekly visits to each of three outpatient treatment sites. They treat the children who they find waiting there with their mothers. There are always lots of people waiting, but the process is well organised. “We have a ‘circuit’ for new patients, says Jeanne, an MSF nurse specialising in malnutrition. When a mother arrives for the first time with her child, we examine the child, measure their height and ‘do their MUAC’. This involves wrapping a band around their arm to measure their mid-upper arm circumference (MUAC), which gives us an idea of how malnourished the child might be. If, when the bracelet is tightened, it’s red, that means the child is suffering from severe acute malnutrition. If it’s orange, that means the child has moderate acute malnutrition. If it’s yellow, the child is ’at risk’, and green indicates that everything’s fine.”

After being examined, children whose MUAC is red or orange will be admitted to the nutrition programme. “We register the child, record their weight and their temperature,” says Jeanne, “and then we do an ‘appetite test’ to see if the child is eating normally. The child is given a ration of therapeutic food, according to how much they weigh. We give them an hour to eat what we’ve given them. Generally they down it very quickly!”

Next, an MSF nurse screens the child for any other potential medical problems. She talks about malnutrition and basic hygiene with the mother, and a general course of treatment is prescribed: antibiotics for five days to deal with potential infections; an antihelminthic to get rid of any parasites; then a dose of vitamin A, all in the form of tablets. “We also make sure that the mums understand that the ready-to-use therapeutic food sachets should only be given to her malnourished child, and not to the child’s healthy brothers and sisters,” says Jeanne. Finally, the child is vaccinated against measles, if they haven’t been vaccinated previously.

The child’s mother goes to MSF’s pharmacy to collect the pills and one week’s worth of therapeutic food. She also receives a bed net – vital for protection from the mosquitoes that carry malaria – as well as a blanket and a bar of soap. The nurse makes an appointment for her to come back on the same day next week.

In some cases, children are referred to the hospital. “If we see from the test that the child has no appetite,” says Jeanne, “we usually refer them to the hospital to be put under observation, as that means that there’s something wrong.” Children with severe acute malnutrition are also referred to hospital if the nurse detects complications. Once in hospital, children who have no desire to eat or who are suffering from respiratory problems need to be fed through a naso-gastric tube.

But for most children, the appointment ends with them going straight home with sachets of ready-to-use therapeutic food. They come back a week later, the mother presents the follow-up card that she was given, and the child has a second consultation. Again the child is weighed, has their MUAC done, and is prescribed therapeutic food for another week. This continues until the child is ready to be discharged from the programme. “The average duration of outpatient treatment is 30 days,” says Jeanne. “The minimum is three weeks and the maximum eight.” Children are considered ‘cured’ when their mid-upper arm circumference measures more than 125 mm.

MUAC measurements give a precise indication of a child’s muscle mass and reflect their nutritional state. Sometimes another measure is used, which is the relationship between the child’s weight and height. If a child older than two years old and taller than 85 cm has a MUAC between 125 and 134 mm, they may also need to receive treatment for malnutrition.

Hospital care in a therapeutic feeding centre

MSF doctor Kai spent three months in Yida. He worked in the hospital where children suffering from acute malnutrition were being treated. For the most part, these children were over the age of five. They were also suffering from medical complications like basic respiratory infections, diarrhoea or malaria. In general, children are admitted to hospital for six or seven days, after which they join the outpatient feeding programme. Kai has seen many children go through treatment at the hospital, but one child in particular stands out.

“There was a three-year-old little boy whose mother was blind. He had already been hospitalised twice before for severe acute malnutrition, but his mother refused the treatment. He had been fed through a naso-gastric tube because he wasn’t eating, but his mother felt the tubes on her child’s face, couldn’t handle it, left the hospital and took him with her. Some of my colleagues eventually found her in the camp and convinced her to come back with the boy and his sister. The state of the little boy had seriously worsened. His body was covered in oedemas [swellings]; he had a respiratory infection and wasn’t eating. Without treatment, he would have surely died. Because he wouldn’t eat, we put in the naso-gastric tube again and we also gave him antibiotics.

He stayed four weeks and became the darling of the MSF team! His seven-year-old sister was with him all the time. She fed him therapeutic milk through the tube, then washed it out afterwards. Once he had started to eat the therapeutic food, she also washed his plate. She took him outside to get fresh air and she helped the mothers who had just arrived at the hospital with their children.

When he arrived, the little boy didn’t have the energy to eat and he never smiled, but it wasn’t long before he started to get better. Then he began to speak, to walk, to play, to smile... and eventually he was able to leave the hospital.”