Scoop situation - Field Exchange - Emergency Nutrition Network

Field ArticleAdmission criteriaIn Kabul, many mothers complain of a lack of breastmilk and believethat this is due to stress and not eating enough good food. Motherspresenting with breastmilk insufficiency raise a number of challengesfor treatment of infants in feeding centres. The admission criteria andtreatment of these young infants in the TFUs in Kabul has evolved overtime. In 2003, the criterion of ‘mothers milk insufficiency (MMI) 6 , wasadded to the existing admission criteria. In June 2005, the criteria wereamended further to admit infants with a weight-for-length less than orequal to 80% if the mother reported she was suffering from a ‘lack’ ofbreastmilk and the infant was not gaining or was losing weight at home.Admission criteria at the time of the study in 2006 for this age-groupthus comprised a combination of anthropometric criteria, weight criteriaand difficulties in breastfeeding (see Table 1).The protocols that have been developed to manage this age-groupinvolve increasing the production of breastmilk through the supplementarysuckling technique (SST) (see Box 1). The aim is that infantsunder six months should be discharged when gaining weight andexclusively breastfed, independent of their anthropometric status. TheSST for relactation has been implemented systematically in the KabulTherapeutic Feeding Units (TFUs) since August 2004. This articledescribes one of a series of studies aimed at improving the managementof these young infants and their mothers.Study ObjectivesThe aim of the study was to evaluate the impact of the SST during theperiod of management in the TFU (including the support, advice andactivities proposed by the psychosocial workers). Analysis was basedon data found in registration books, therapeutic cards, psychosocialforms (included family history, medical, treatment, feeding history ofthe infant, caregiver-infant observations), MMI forms (which focus onobserved and reported infant feeding practices and health status ofmother) and interviews with mothers. The indicators assessed wereweight gain (g/kg/d), increase in estimated breastmilk quantity duringthe period in the TFU 7 and evaluation of SST application.The study also planned to assess progress of the infants on dischargefrom the TFU, including weight gain, breastfeeding status, and feedingpractice. Follow-up of the patients was based on analysis of the ‘dryration books’ in which infants are registered at discharge and wheretheir weights and heights are registered during follow-up.The target group comprised infants under 6 months of age andinfants aged 6 months or over with a weight of less than 4 kg.Data for each of the infants were entered into a spreadsheet andanalysed using excel. Anthropometric indexes were calculated usingEpinut version 5 and were exported into the excel spreadsheet.Limitations of the studyThese included;• The size of the study was limited to infants discharged between02/01/06 and 23/04/06.• Some therapeutic cards (14 %) were unavailable due to poor storageand/or retrieval systems.• The data on the therapeutic forms were often incomplete, e.g. onbreastfeeding or use of the SST.• Weight and mid upper arm circumference (MUAC) measurementswere typically reported as rounded up figures. This was despiteweighing scales accurate to the nearest 10g being available in all ofthe TFUs.Figure 1FrequencyAge distribution of infants under six months and/orweighing less than 4kg• The proportion of infants that were lost to follow-up after dischargehindered outcome evaluation.Age profileData were analysed on the management of 94 infants aged less than 6months old and/or less than 4kg discharged between 2/01/06 to23/04/06 from three TFUs – Ataturk TFU (n=25), Indira Gandhi TFU(n=36), and Maiwand TFU (n=33).The mean age of the sample was 4 months (see Figure 1). There weremore boys (63%) than girls (37%). Twin births accounted for 17 % (n=16)of these admissions. According to the recorded TFU data, 18 infants hadsome form of disability and/or developmental problem that couldaffect feeding (including cleft palates, and suspected Down’sSyndromes).Admission criteriaGiven the lack of consensus on admission criteria for infants under 6months, severe and moderate acute malnutrition are referred to accordingto the criteria commonly applied to infants and children from 6 – 59months of age.Thirty-five infants met the classic criteria for severe acute malnutritionin this age-group of whom:• 8 had oedema• 21 had W/H < 70 % with no oedema• 6 infants were over 6 months and weighed less than 4 kg.Nearly one-third (31%, n=29) of infants under six months were admitteddue to MMI but were not severely malnourished. Of these, 26 hadmoderate acute malnutrition (70 % < W/H 80 %) and three infants werenot malnourished according to anthropometric criteria 8 . Reasons foradmission did not vary significantly according to gender or from oneTFU to another.6Maternal Milk Insufficiency (MMI) is where a mother reports a lack of breastmilk, howeverthere is no quantifiable measure of this on admission.7This data is not presented in this field article but is available in the full study report fromthe authors (see contacts at the end).8An additional 3 infants had missing length data (therefore no W/H calculated).9Length data on 91/94 was available.10The lengths of 3 children were not measured. These children weighed 1.5, 1.5 and 1.7 kgrespectively (they were aged 1 day, 2 months and 1.5 months respectively).11One infant was classed in the category ≥ 6 months and