Ambulatory treatment of severe malnutrition in Afghanistan

By Emmanuelle Lurqin

Emmanuelle is a paediatric nurse and since 2000, has worked with MSF Belgium on nutrition programmes in Angola, Burundi, and Afghanistan. She is currently working with MSF Belgium in the Ivory Coast.

During 2002, the author spent nine months in Faryab province, Afghanistan working as a nurse with MSF Belgium on the nutrition programme. This article describes her experiences in ambulatory care of severely malnourished children.

Faryab province is in a remote and poor area in the north of Afghanistan. There is little infrastructure, a high risk of disease outbreaks such as cholera and measles, and malnutrition is endemic. Communities have limited access to health care and education. MSF has been present in the province since May 1997, with programmes focused mainly on primary health care, nutritional interventions and responding to medical emergencies.

Malnourished infant with mother wearing burka

Following many years of war and more than three years of drought, Afghanistan was facing a food crisis situation. According to a WFP food security assessment carried out in July 2001¹, Faryab was one of the worst affected provinces of the country. A number of evaluations² demonstrated that the food security of the population was extremely weak, and that there was extensive malnutrition as well as outbreaks of scurvy. Impoverished families had lost their land. Families who had land could not cultivate it because they had no seeds or they had lost their animals. A lot of cattle died during the drought. The quantity and quality of food aid distributed in the province was inadequate and vulnerable people in remote areas were not being reached.

The population used different mechanisms to cope with the situation. Some families sold personal belongings, including livestock and land, in order to get money to buy food. Some families even had to commit their daughter to marriage at an earlier age than usual in order to secure income. Many families resorted to loans from the wealthy while many men moved to towns or to Iran in order to find employment.

At the time of writing this article (January, 2003), the food situation remained precarious and the political and security situation unstable. MSF were operating five feeding centres in the province with an average of 2,200 beneficiaries (moderately and severely malnourished children and pregnant/lactating women).

Rationale for ATFC

A number of constraints made the implementation of a conventional 24-hour therapeutic feeding programme problematic in Faryab province:

• Cultural values and practices in Afghanistan determined that the freedom of women was still very restricted. They could not leave their home for long periods and were required to spend long periods at home undertaking domestic or agricultural tasks, as well as caring for their children and husbands. It was not acceptable for women to spend a night outside their houses and they would have to be home before dark. It was, therefore, extremely difficult to ask mothers to stay overnight with their children in a therapeutic feeding centre (TFC).
• Accessibility to health centres was very difficult in this mountainous remote area. The roads were of very poor quality, which meant a mother had to walk an average of four hours to the feeding centre, and another four hours to return home. During the winter, the situation was worse as the roads were muddy or snowy.
• It was not easy to find educated people in this rural area and it was very difficult to employ women, since they were frequently not allowed to go out and work.

More recently, there has been much discussion in the literature about community based therapeutic feeding programmes for treating severely malnourished children. Potential advantages of this approach are that it allows a decentralised programme thereby ensuring better coverage, it increases accessibility and acceptability and does not undermine family units. However, intensive medical/nutritional care and monitoring are much more difficult in outpatient treatment. Furthermore, individually tailored dietary regimes are impractical. Also, individually tailored dietary regimes cannot be employed.

Given the constraints of a 24 hour therapeutic feeding programme, and bearing in mind the advantages and limitations of community-based care, MSF opted to implement an Ambulatory Therapeutic Feeding Centre (ATFC).

Ambulatory care approach

This ATFC approach in Faryab involved malnourished children attending a feeding centre on a weekly basis. The feeding centres in Faryab province enrolled both moderately (supplementary feeding) and severely malnourished children. Admission criteria were based on weight-for-height (W/H), mid-upper arm circumference (MUAC), presence of oedema, or children transferred from the supplementary feeding programme. All malnourished children under 130 cm were eligible for admission.

Medical treatment

A complete physical examination, including a health and nutrition history, was undertaken for each child. Where possible, physical examination by a doctor was carried out weekly. Systematic treatment was administered according to standardised protocols, and any additional diagnosis individually managed. All children received measles vaccination.

Nutritional treatment

Nutritional treatment was based on "ready-touse therapeutic foods"(RUTFs) -Plumpy'nut and BP100. The quantity of RUTFs supplied per week varied, and was based on providing each child with 200 Kcal/kg/day. In addition, a supporting family ration was given to the mothers, to supplement - rather than substitute - the general food distribution. This comprised 6 kg of wheat per week, and provided an average 471 Kcal/person/day (based on a six person family). For infants under 60cm in length who were admitted to the ATFC, a support ration was given to the mother. This comprised 2.3 kg of premix (400g oil, 100g sugar, 1.8 kg corn soya blend), corresponding to 1540Kcal/woman/day.

Follow-up

After the medical consultation, the children remained as long as possible with their mother in the "TFC room". In general, the mothers were able to stay for 4 hours, during which time the nurse performed a number of tasks:

• checked the card of each child, measured the weight gain and investigated any cases of weight loss
• ensured that the child took the drugs administered (first treatment dose was given in the centre)
• provided standard oral rehydration salts (ORS) to each child who presented with diarrhoea (ORS given on the spot and two packets to take home).
• gave a cup of therapeutic milk, 'F100' , to each severely malnourished child.

Health education

The health educator attempted to ensure the carer correctly understood the advised diet and importance of the treatment, and tackled health education issues (breastfeeding, complementary feeding practices, basic hygiene rules and main diseases).

Severely malnourished child with mother

Programme review

For the period January to October 2002, clinical records for 635 severely malnourished children were analysed and a review performed using traditional TFC indicators. As this type of programme is relatively new and has not been implemented in many places, it is difficult to compare results with a 'norm'. However, it is considered worth sharing findings from this programme, despite difficulties with their interpretation.

Nearly half of children were admitted under weight for height criteria (see table 1), and the female: male sex ratio was 1.19. Most of the new admissions were children with heights between 60-85 cm, corresponding to 6 to 18 months (see table 2). This age profile suggests that poor breast-feeding and complementary feeding practices were significant factors in the presenting cases of malnutrition. In our experience, many mothers continued exclusive breastfeeding for longer than six months (sometimes until 2 years of age).

Outcome indicators

In terms of outcome, the mortality rate of 6% was slightly higher than the MSF target of less than 5% mortality for a 24-hour TFC (table 3). An increase in June and July (19.4% mortality in July), and decreases between August and the end of the year (from 7.6% to 2.2%), most likely reflected seasonal diarrhoeal patterns. Where possible, the local team investigated causes of death. The reasons for death most commonly given by mothers were fever, diarrhoea, vomiting or cough

Defaulters

A child was defined as a "defaulter" after three consecutive absences from the centre. The high default rate in the programme (23.8%) was close to the MSF 'alarming' value for a 24-hour TFC (target <25%). In an attempt to identify reasons for defaulting, community follow-up of 29 defaulters by the nutritional team identified the following reasons, as reported by the mother:

• Ten children (34.5 %) defaulted due to illness of the child or mother.
• Seven children (24.1 %) had to accompany mothers to the field where they were cultivating land.
• Seven of the children (24.1 %) didn't return for various other reasons, e.g. not enough food distributed at centres, problems at home.
• Five of the children (17.3 %) had died.

As some of the children identified as defaulters will undoubtedly have died, the 6% mortality rate is likely an underestimate.

Weight gain and length of stay

Average weight gain in the programme was 6.1g/kg/day and the mean length of stay was 57 days, with little monthly variation. While these figures compare unfavourably with traditional TFC norms (target weight gains: 10- 20g/kg/d, target length of stay: < 30 days), results really need to be compared with other similar experiences and, ideally, with norms developed specifically for this type of programme.

Programme constraints

A number of factors may have adversely affected programme performance:

• Lack of medical and nutritional follow-up of children.
• Difficulties for mothers in reaching the centres.
• Maternal level of knowledge about appropriate child caring practices and correct diets was very poor, and certain cultural beliefs handicapped the work of the centres.
• Mothers often failed to recognise whether a child was ill and would therefore not go to the health centre when it was necessary. Many of the malnourished children had a history of disease when they arrived at the feeding centre.
• The staff working in the feeding centres were not always skilled and lacked experience. MSF therefore had much training to do. Due to cultural constraints, there was also a lack of women available to work and mothers did not find it so easy to confide in male staff.
• The RUTFs are not the ideal initial treatment for severely malnourished children, especially small babies who may find it difficult to swallow³.

Lessons learned

The ideal strategy for treatment of severe malnutrition would be inpatient care, followed by community-based care and home management. However, despite the constraints of the ambulatory approach in Faryab province, a number of positive aspects of this strategy emerged. The programme was well accepted by mothers who were motivated to come, partly because their child received a full medical examination. Interest in the health education component seemed to increase, with mothers agreeing to stay longer to receive advice. RUTF was well accepted by the children. Also, children began to respond more quickly, both medically and in terms of weight gain, following the introduction of more systematic medical examination by doctors at the end of July 2002.

Through the course of the programme, some key lessons were learned which may help to improve future programming outcomes:

• Sustained medical follow-up of severely malnourished children is essential, ideally a weekly consultation with a doctor.
• Training of staff is critical in order to maintain the quality of the programme and the dynamism of the teams.
• Health education can be vital. Malnutrition in Afghanistan is not only due to a lack of food but also due to a lack of knowledge of mothers regarding breast-feeding and complementary feeding practices, as well as cultural beliefs.
• Where there are high levels of default, teams should actively search for patients in the community to try and understand the main reasons for absence. However, this activity requires a lot of time, as well as human and material resources.
• Children with severe malnutrition should be admitted to a residential care centre for the initial treatment and closely monitored during this critical early phase. The rehabilitation phase can be conducted in a centre or at home.
• A system of community outreach workers should be organised to allow follow-up at home. The outreach workers should check the children's progress and refer the ill children back to the feeding centre or the closest clinic. They should also reinforce the educational messages discussed in the centres with the mothers. Mothers should be encouraged to disseminate the health messages inside the community.
• A system of outreach teams will also allow active screening for malnourished children, which should increase programme coverage.
• Collaboration with the Ministry of Public Health and the first-line health systems is essential.

Outstanding issues

There are a number of outstanding issues that necessitate further research.

• The composition of RUTF's (high-protein diet with sodium and iron) is not ideal for severely malnourished patients in the initial phase of treatment, especially oedematous patients. More research on the use of RUFTs for kwashiorkor patients is needed.
• Ongoing research on the cost-effectiveness of ambulatory treatment is needed. In Faryab, MSF employed an average of 12 people per feeding centre, and one local doctor working for the whole nutrition programme. The supervision of these staff required time as well as financial and material resources.
• There is a need to make the management of severe malnutrition, currently based on imported foodstuffs, more sustainable. While emergency relief programmes may be generally well funded, long-term programmes are sometimes under-financed. Even if the price of Plumpy'nut were to decrease, it would remain comparatively expensive. Production of feeds based on locally available foodstuffs is carried out in some countries but more information on these experiences is needed.

Finally, analysis of outcomes, including programme coverage, is essential for evaluating programme impact. However, to truly analyse efficacy of the ambulatory programme, further research is needed. This will require a collation and analysis of experiences in other contexts in order to refine the strategy and identify 'norms' for programme performance.

For further information, contact Sophie Baquet, Nutritionist, MSF B at email: sophie.baquet@msf.be

¹WFP Food security assessment, Vulnerability Assessment and Mapping Unit, July 2001

²Nutritional survey in Qaisar and Almar districts, Faryab province, Northern Afghanistan, MSF-B, August 2001; Nutritional survey in Qaisar and Almar districts, Faryab province, Northern Afghanistan, MSF-B, July 2002; Vulnerability assessment in Northern Afghanistan, Faryab province and Sar-I-Pol, Epicentre/MSF-B, January 2002; Field visit report Afghanistan, Sophie Baquet, MSF-B, March 2002. Field article

³RUTFs are not intended for initial treatment and are not indicated for use in young infants