guidelines for the integrated management of severe acute malnutrition

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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”
ACF-In Guidelines for the integrated management of SAM Emotional and physical stimulation 57 mats, and with the mother or a play guide. There is no evidence that this increases nosocomial infections 70 Massages are also an important component either to reinforce the mother-child relationship and to stimulate a child’s physical and psychological development. 71 2. Physical activity Physical activity itself promotes the development of essential motor skills and may also enhance growth during rehabilitation. For immobile children, passive limb movements and splashing in a warm bath are helpful. For mobile children, play should include such activities as rolling or tumbling on a mattress, kicking and tossing a ball, climbing stairs, and walking uphill and down. The duration and intensity of physical activities should increase as the child’s condition improves. There should be a member of staff nominated who has overall responsibility for all these aspects of care of the malnourished. The toys shown in the diagram below should be made and used in both the in-patient units and the homes of the malnourished children. 70 Most nosocomial infection comes from the staff moving from patient to patient without their washing hands, from the caretakers, from contamination of the diets and storage of feeds before they are given to the child and from inadequate facilities for washing, and the disposal of excreta. Putting children together to play does not represent an important additional danger. 71 “Manual for the integration of child care practices and mental health within nutrition programmes” page 32 Baby massage
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Cover photography: © ACF, Anne-Dom
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