Managing acute malnutrition; Case study in St. Francis Xavier Hospital
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“So I wondered, how could this be in a middle-income country? What might have happened to this child and what did somebody not do for him?” These and many other questions run through my mind.
Similar cases had been seen in the ward but not as severe as this one.
Management of Severe Acute Malnutrition (SAM) in child health is a specialty, and requires careful assessment of the patient and then resorting to a special protocol for its management.
It starts from welcoming the caregiver. You will always wonder how it happens; how someone could live with a child like this and never recognise the deterioration.
Well, this is not the focus because it has already happened. So what do we do? We took a quick history to have an idea of how long the child has been in that state.
What matters to the caregiver, the age and sex of the patient, how long this condition had been there, any history of fever, vomiting, diarrhoea, presence of appetite, just to mention a few. Sometimes, caregivers may not tell you the truth, of course that is all the history you can get. History taking plays a very important role in the management of SAM because the rate of recovery is proportional to the duration or onset of the disease.
Examination of findings
Another important aspect is the examination of findings, which include the conscious state or activity, hydration status, severe wasting, weight and length or height, left mid upper arm circumference (MUAC), dermatosis (breaking or peeling or flaking of the skin), oedema (body swelling- generalised or local), pallor (anaemia) and febrile (warm to touch) . This informs your decision on how to plan the management, what kind of feed, the route of administration, skin management, among others.
The next is to investigate and rule out other chronic systemic diseases such as HIV, TB, juvenile diabetes, as well as other acute infections such as pneumonia, malaria, urinary tract infection (UTI) and anaemia.
In the case of this particular patient, he was brought to the hospital, accompanied by both parents in a conscious state with appetite.
He was severely wasted with baggy pants, extensive dermatosis and pressure ulcers on the buttocks. He was neither pale nor febrile, but had bi-pedal edema.
Unfortunately, the father disowned the child, claiming that he only accompanied the mother and child by offering assistance to them. It was obvious that the father recognised that something was wrong for which reason he declined to disclose his identity but did not know what to do.
This particular child was on admission for only 19 days until he attained, and even passed the target weight; that is from SAM to obesity.
There is a protocol for the management of SAM once they are recognised and admitted into the programme. It should be noted, however, that, the SAM patient is so special that, strict adherence to the protocol is of paramount importance.
Regular monitoring
Regular examination to monitor improvement in conscious state, daily weighing done to monitor any weight gained, resolution of edema, normalising temperature, healing dermatosis and pallor improved.
When he was admitted, he passed the appetite test and continued to eat freely the ‘plumpy nuts’, while his dermatosis was being managed. Within seven days, the patient had started improving so well that it was difficult to believe that he was the same child who was admitted with SAM. Everybody was very impressed.
He had become more active, smiling and playful, gaining weight by the day and his dermatosis was nearly healed. By the time he was 12 days in the ward, he was already complementing the ‘plumpy nuts’ with home feeds; dermatosis completely healed and almost reached his target weight.
By 17 days, he had passed the target weight and was eating so well the home feeds that were available in the caregivers’ community, while the ‘plumpy nuts’ had been reduced and ultimately withdrawn.
When he had greatly improved, his father accepted him as his child. Finally, on July 21, 2010, he was discharged from the ward to continue with the Community Management of Acute Malnutrition (CMAM), that is, to continue home feeds that will maintain the well-nourished state.
He came for review on two occasions, one monthly apart, and had maintained his well-nourished state.
By Dr Ernest Konadu Asiedu/Ghana
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