GULU UNIVERSITY MEDICAL JOURNAL

Recommendations

Info

Gulu University Medical Journal (GUMJ) 2009/2010 Vol 5. without oedema (Figure 1) admitted to the Lacor hospital in June and July 2002, before the administration of Nutricam, did not show, in most cases, the expected catch-up growth after nutritional rehabilitation with milk. Finally, a significant proportion (>10%) of mothers dropped out of the programme, often because of discouraging results. Figure 2 shows the weight curves, in grams of body weight, of 20 children, without oedema, who received Nutricam starting from the first week of August 2002. There was a conspicuous improvement in the slope of many weight curves compared with pre-Nutricam values. The average daily oedema-free weight gain was 21 g (12–29 g) with milk alone in 2001, 35 g (25–45 g) immediately after the intervention in 2002 and 59 g (51–68 g) at the end of the first year of intervention 2003 (See Figure 3). Days-in-care correlated with weight increments, but did not change significantly over the three years of the study, whereas the mean weight increments during treatment (an average of 20 days) increased from 525 g in 2001 (before Nutricam), to 771 g in 2002, and 1,274 g in 2003. Mean growth increments increased significantly as the study progressed. Figure 4 shows the numbers and trend of survival outcome as a per cent of cases admitted to hospital each month. The top regression line shows the per cent of cases discharged as ‘cured’ (namely, children who attained 85% weight-for-length, which increased from 54.5% in January 2002 to 93.3% in August 2004. The lower regression line shows the per cent deaths and per cent of ‘lost’ cases. Mortality and ‘lost’ rates are considered collectively as ‘overall failures’: these were 45.5% in January 2002 and 6.7% in August 2004. The death rate was 21.2% in January 2002 versus 2.9% in August 2004. Table IV shows the averages (and standard error) for each outcome variable (cure, death, lost –default) in the three years of the study after correction for the number of cases admitted in each study period (multivariate analysis). Again, the differences among years are highly significant. The results were so good that the hospital decided to introduce permanently Nutricam in the nutritional rehabilitation. In a further study, six years later, we demonstrate conclusively how Nutricam helped to treat malnutrition. 5620 patients admitted in the St.Mary’s Hospital in Lacor, Uganda, were studied from the second half of 2002 (after introduction of Nutricam) to 2007, in order to observe long term results. We included in the study all the patients admitted to the Nutrition Unit according to the WHO criteria (7) avoiding any selection bias. Over these 6 years 74,7% of patients were admitted because of marked oedema, 17,3% because of low weight for height and 6,1% because of very low Mid Upper Arm Circumference. As you can see in Figure 5, the average oedema-free weight gain was 1694 gr for cured patients. The average daily oedema–free weight increment was 66,7 gr for males and 62gr for females. The survival outcome is still confirmed, as the previous paper. Figure 6 shows that the overall percent of children cured is 78% and the percent of dead is 11%. These results are similar to those published in the previous study and very different from those one of the before-Nutricam period. Mortality in this setting is still very high. To understand the causes of this finding we explored the clinical data of the children. The average of days in care was 23,9 days/child but the distribution shows two peaks (fig 7). The first peak is in the first few days after admission: this is the cohort where most of deaths are endowed. They come to the Unit in extremely severe conditions and just cannot take any advantage from the nutritional program. In our setting, more than 50% of patients who died did not survive to the sixth day after admission and the highest peaks of deaths are in the second and third day after admission These data show that this high mortality cannot be attributed to a failure of the nutritional program but it is due to the late referral of the extremely wasted children with severe complications. Intensive care facilities, not jet available in the unit, could reduce these fatalities, but will not be the most adequate solution to the problem. It is clear that the best solution is to intensify the nutritional screening in the villages and, then, support community-based treatment for moderated malnourished children. Gulu University Medical Students’ Association (GUMSA) Passion for life 18
Gulu University Medical Journal (GUMJ) 2009/2010 Vol 5. In conclusion, Nutricam plus milk was more effective than milk alone in nutritional rehabilitation of severely malnourished children. Oedema disappeared rapidly and daily weight increments rose significantly compared to treatment with milk only. Nutricam did not affect the length of stay in the unit, probably because the children were severely ill and were affected by severe acute diseases (diarrhoea, malaria, pneumonia, tuberculosis etc) besides malnutrition. The change observed over time in the outcome variables (increments in weight and survival) may not be entirely due to the nutritional intervention. During the two years after the intervention started, various improvements were made in the Nutritional Rehabilitation Unit, although the care of severely malnourished children remained unchanged. Moreover, the number and category of medical personnel in the Nutrition Unit did not change, and no additional motivation was given to medical personnel or caretakers/mother to improve care. During the study, the number of admissions increased and the status of the children at admission was worse probably of the instability caused by insurgency that caused many families to abandon their villages. Nutricam is locally feasible at a low cost (about 134 Ush/serving, including labour and fuel). It is well accepted by the local population, easy to prepare and very effective for nutritional rehabilitation. Nutricam was not intended to supply all the daily energy requirements, but is well suited as a supplement to mother’s milk. At the Nutritional Unit, mothers/caretakers are offered nutritional education twice daily by the Health Educator and they participate in the preparation of Nutricam for at least 5 days before their child is discharged from hospital. The nutritional intervention is not persistent if it is not handed to the mother’s responsibility, in order to transfer this attitude to the daily village life. Nutritional failures decreased by more than 50% after Nutricam. From August 2002 to September 2004, we estimated that 454 children were saved from nutritional failure: 216 less deaths and 238 patients less lost-to-treatment versus the period from January to July 2002. This study demonstrates the efficacy of supplemental feeding with a varied protein source for severely malnourished children. This intervention did not require a special project or sponsors, just one person at a cost of only 220 Euro/month for the entire action. The hospital management continued this intervention, which was also implemented in other hospitals in the region. It cost about 3000 Euros to build the kitchen and purchase equipment for each new therapeutic feeding centre. The cost of providing powdered milk by international agencies is 32,370 Euro/year for the same group of children who entered our study. The results of nutritional rehabilitation with milk alone are often disappointing. Moreover, milk is not always available out of the hospital, which means that many children relapse. The widespread use of the porridge together with milk, which resulted in better outcomes than milk alone, could produce saving thus releasing resources for other uses. Lastly, nutritional rehabilitation is essential to survival for the many children with malnutrition in developing countries, but it cannot be based solely on powdered milk. The Lacor study highlights the need to involve local communities in the selection of locally available nutritious foods for children to prevent and treat malnutrition. In conclusion the most effective treatment of children’s malnutrition is early local identification of at risk children and secondary prevention: which means to treat the moderately malnourished children before severe malnutrition ensues. Immediately after this intervention the use of local ingredients to prepare supplementary feeds for breast fed children has been proven to be an effective intervention at very low cost. Also in the hospital settings, an especially in the Nutrition Rehabilitation units, widespread all over the developing world, supplementary feeds made by local ingredients are largely preferable to expensive, industrially packages feed supplements. The solution to malnutrition is not to produce, transport and distribute ‘therapeutic’ feed supplements: they are received as drugs and as such do not change the familial attitudes towards children feeding. These products are not available at home and are finally very expensive in terms of local currency. Many mothers sell their goats and garden products to pay for a tin of dried milk or few packages of RTUF on the black market. Western-type intervention is justified in emergency, but children malnutrition is Gulu University Medical Students’ Association (GUMSA) Passion for life 19
Page 1: Gulu University Medical Students’
Page 4 and 5: Gulu University Medical Journal (GU
Page 68:
Gulu University Medical Journal (GU
show all

GULU UNIVERSITY MEDICAL JOURNAL

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?