Feed on

Posted by Bibhusan Basnet

Community malnutrition screening and treatment has been one of our missions since the establishment of Nyaya Health.  Malnutrition is present in 60% of children under the age of five in Achham, where we have our working base.  It is a tragic reality, and our fight against malnutrition is underway.

Bayalpata Hospital runs a community based management of acute malnutrition (CMAM) program, in which Madan dai (Health Aide) is the front line for screening all patients under five that visit our outpatient department.  His work includes measuring children’s height, weight, and mid upper arm circumference.  After analyzing the information, Madan dai determines whether the child as within the “green zone” (properly nourished), “yellow zone” (at risk of malnutrition), or “red zone” (acute malnutrition).

Madan Kunwar, Health Aid measuring the mid-upper arm circumference of one a patient, as a screening for childhood malnutrition.

Patients are then received by our health assistants or doctors in the outpatient department, where they confirm the patient’s assessment and look for any other medical complications.  Most cases of under-nutrition are due to lack of proper feeding techniques, decreased production of mother’s milk, and decreased availability of time for mothers to feed their children.  Due to the extreme poverty in the area, as well as the high rates of HIV, tuberculosis, and other debilitating diseases, many mothers have limited availability to tend to their children.  In addition, women in Achham are primarily responsible for farming, cooking, cleaning, and household activities, which further limit the amount of time that they can dedicate to their children’s nutritional needs.

Mothers with children in the yellow zone are advised to make fortified feed (sarbottam pitho) at home to feed to their young ones.  The sarbottam pitho is comprised of at least four kinds of cereals that are easily available at home.  It is advised also that these patients come for frequent follow-up visits, in order to monitor their progress.  Getting patients to follow-up on their medical care is itself a major challenge for our whole team.

Patients found to be within the red zone who also exhibit medical complications are admitted to the inpatient department for aggressive management.  They are provided with antibiotics, fluid management as needed, and Plumpy’Nut nutritional supplements for fast weight gain.  It has always been challenging for the clinicians and nurses on duty to encourage mothers to feed their little ones ready to use therapeutic foods (RUTFs).  “They do not take it. How can we feed them with this paste?” is what they always say.  We regularly counsel mothers on the benefits of feeding their children this valuable paste, but the process sometimes gets frustrating when, despite our consistent efforts, the mothers are reluctant to feed their children the Plumpy’Nut supplements.

A few days ago, I noticed Madan dai feeding Plumpy’Nut to a child in the inpatient department.  Surprised, I asked him what he was doing.  He reluctantly said that the child was his son, and that he had been admitted to the hospital with severe malnutrition and pneumonia.  What an irony!  This intrigued me a lot.

Madan dai, who knows the details of the CMAM program, hadn’t noticed that his own son was suffering from malnutrition.  Was this because he didn’t have adequate time to monitor his son for appropriate weight gain?  Or perhaps his wife didn’t have enough time to spend feeding their kid?  Many women do not have time to feed their children, which might play a significant role in this problem.  No wonder the rate of malnutrition in Achham is so high.  Is there something we can improve more?  Can we do more rigorous monitoring?

Madan Kunwar Health Aide entering the patient’s height, weight, mid-upper arm circumference, and z -scores in the community management of acute malnutrition register.

Malnutrition screening and management has become even more challenging.  Recently, after discussion with Dr. Payel Gupta (Director of Clinical Operations) and Jackie Pierson (Director of Data and Evaluation), we have set up growth charts for every child that come for our services.  By using these charts, we can determine whether or not a patient is exhibiting a good growth pattern, and if there is a problem we can address it in a timely fashion to prevent malnutrition.  The areas where the malnourished children come from will be noted, and our female community health volunteers (FCHVs) will be mobilized to follow-up with these patients. The fight against malnutrition continues; though the road is troublesome, we shall leave no stones unturned.

Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is the former Medical Director for Nyaya Health.

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