There are some patients that keep me up at night — the ones I worry about even when medical care is optimal. Patients with severe acute malnutrition fall into this category.
It’s difficult to predict which child with severe acute malnutrition will survive and which child won’t make it. All too often, I have seen a child on the pediatric ward who seems to be doing well, only to be told the next day at morning report the child had died.
It was 6 p.m., and I had been seeing patients since the morning, along with an intern doctor. A nurse on the neonatology unit informed us there was a new patient to see.
Our new patient was 21 days old. Her mother had not received any prenatal care and had delivered at home —unusual here in Rwanda, where around 90 percent of women give birth in a health facility. These were definite red flags in her history.
The mother reported she was unable to produce breast milk. She had been feeding the infant formula, which she obtained from a neighbor, about twice a day. She came to the hospital at the neighbor’s prompting. At admission, the infant weighed 1 kg., or approximately 2 lbs. 3 oz. She was tiny but surprisingly vigorous. Nutrition seemed to be her only problem. She had not had any signs of infection, common among children with acute malnutrition. Still, these are the children I worry about. This one in particular was so young and so small.
Malnutrition: more than feeding issues
According to the World Health Organization, malnutrition is a contributing factor in 45 percent of pediatric deaths. Many people think caring for them is just a matter of feeding, but it is much more complex than that. These patients are so fragile. They are at risk for infections, have difficulty maintaining their body temperatures and can develop electrolyte abnormalities. Because all of their muscles are weak, including their heart, they are at risk for heart failure from fluid overload if given IV fluids.
There are protocols for taking care of children with malnutrition. However, the most experience is in children above six months of age. This child was a mere 21 days old. Her birth weight was unknown. It was also not clear if she had been a full-term infant or was born prematurely. Despite appearing healthy overall, this infant definitely had me on edge. The intern doctor and I made our plan for her care. Her blood glucose was OK. Kangaroo mother care (when the mother holds the infant close to her chest) provided warmth and kept her temperature within the normal range.
Antibiotics were given to treat any hidden infections, which are common among malnourished children. Feedings were scheduled every three hours, day and night, and weight was monitored daily.
The next morning, my first stop at the hospital was the neonatology ward to check on this patient. I was assured by the nurses, who had cared for her overnight, that she was doing OK.
On a path to health
I split my time working at two different district hospitals in Eastern Rwanda, so I don’t always have the continuity of patient care that I like to have. But every time I was on the neonatology ward I would look for her. Patients often switch beds as a more desirable space becomes available, so sometimes I wouldn’t see her immediately, but then would spot her in a different part of the ward.
She remained strong and free from infection. She tolerated her feeding and began gaining weight. The nurses taught her mother how to care for the baby. They showed her how to prepare the formula properly. They showed her how to feed her, and how often. They helped her with kangaroo mother care to keep the baby warm. Eventually, it was time for discharge, and they taught her to watch for danger signs and when to seek medical care.
Usually, that is the end of the story: the patient gets discharged from the hospital. But this story was different.
A week or so later, I went with a hospital team to a health center about 45 minutes from our hospital to do supervision at the pediatric development clinic, a novel medical intervention in Rwanda that follows up with high-risk children. The infant was there with her mother, enrolled in a clinic that will monitor her growth and nutrition along with screening for medical problems and developmental issues.
Finally this child was on a sustainable, healthy path. And I didn’t need to lose sleep anymore.
Jessica Bradford, MD, trained in Internal Medicine and Pediatrics. Her interests are teaching and caring for patients in resource-limited settings.
Bradford spent six years working in Tanzania, caring for children with HIV and teaching local nurses and doctors how to care for HIV-infected children. She also taught Tanzanian medical students pediatrics at the regional hospital. Since July 2015, Bradford has been a Fellow at Boston Children’s Hospital in Pediatric Health Service Delivery. She spends six months of the year in Boston and six months working at two district hospitals in Rwanda as the District Clinical Advisor.
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