guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Emotional and physical stimulation 56
EMOTIONAL AND PHYSICAL STIMULATION 69
As children become malnourished they gradually reduce their activity. When fully malnourished they
do not play, cry, smile, complain or show normal emotions – they become lethargic and feeble.
Because they do not cry when they are hungry thirsty or distressed a busy mother thinks that her child
does not need more attention than she is giving the child. Nurses also neglect children in hospital for
the same reason. Adults respond to the demands of children, if the child does not demand then it is
ignored. This is the main reason why these children should be treated together and separately from
children with other conditions.
Because they do not play, they do not learn. With time this leads to delayed mental and behavioural
development. If this is not treated it is the most serious long-term result of malnutrition. Emotional
and physical stimulation through play programmes that start during rehabilitation and continue after
discharge can substantially reduce the risk of permanent mental and emotional damage.
Many children have witnessed events that are very traumatic emotionally. Children of parents with
HIV/AIDS for example may have seen their mother and farther become ill and die in most distressing
ways. Orphans are particularly vulnerable. With serious famine they may have been discriminated
against within the family by siblings and relatives. In emergency situations they may have witnessed
extreme violence to loved ones. Such psychological trauma frequently leads to post-traumatic stress
disorder and, particularly in older children, can be a major impediment to recovery. The same
problems occur in the caretakers; in these circumstances they frequently need psychological or
psychiatric support or medication.
It is essential that the staff understand the emotional needs of these children and create a
friendly supportive atmosphere. Caretakers must never be chastised and the staff should never
shout or become angry. Unsmiling children need to be picked up, cuddled and kissed. There must be
an educational session that teaches the mothers the importance of play and exploration as part of the
emotional, physical and mental stimulation that the children need. This is an integral part of treatment.
In out-patient settings it is critical that the mothers understand the importance of this aspect of
treatment.
It is essential that the mother be with her child in the IPF and that she be encouraged to feed,
hold, comfort and play with her child as much as possible. Toys should be available in the child’s
cot and room, as well as the play area. Inexpensive and safe toys made from cardboard boxes,
plastic bottles, tin cans, old clothes, blocks of wood and similar materials. They are best because
mothers are taught to make them themselves and continue to make toys for their children after
discharge.
1. Emotional stimulation and play
Care must be taken to avoid sensory deprivation. The child’s face must not be covered; the child must
be able to see and hear what is happening around him or her. The child should never be wrapped or
tied. The malnourished child needs interaction with other children during rehabilitation. After the first
few days of treatment, the child should spend prolonged periods with other children on large play
69 ACF recommendation: See ACF Manual for the integration of child care practices and mental health within nutrition
programmes”