An MSF staff member measuring a child's arm for malnutrition

Tackling severe malnutrition in infants

Gift Farau, a nursing supervisor from Zimbabwe, spent a year at the MSF Hangha hospital in Kenema, Sierra Leone from August 2019. In this article he sheds some light on what an Inpatient Therapeutic Feeding Centre (ITFC) is all about and the impact the hospital’s ITFC is making on the historically high infant mortality rates linked to severe acute malnutrition. 

The inpatient therapeutic feeding centre

The main objective of the feeding centre is to try and get a child to regain their health. When they are at home, they might not be feeding well because they don’t have the appropriate food, or they’re sick and unable to eat. At the ITFC we provide comprehensive management: including therapeutic food with the correct nutrients, and we also address acute and chronic medical conditions that may be a cause of severe malnutrition

Image of Gift Farou and our team in Kenama Hospital
Gift Farau (centre, standing) with some of his colleagues (pre-COVID-19) in Kenema

We have a three-hourly feeding programme for the children. Before feeding them you have to stimulate them. To do this, we try to create a patient-friendly environment, but because there are quite a few infants in the centre, you have to create an individual relationship with the patient and caretaker. If the children have a good relationship with the person who is feeding them, they will be encouraged to eat properly. While the nurses initially do the feeding, the main objective for us is to train, support and assist the mothers to feed the children themselves. 

Quality of eating

Sometimes the parents look more at the quantity of food the child is eating and not how they are eating. For example, a child may take in the quantity that we would expect, but if they vomit soon after then their tiny bodies are not getting the nutrients the need. Ideally, we want the children to eat 100% of the meal but if they can’t, it’s better to get them to eat gradually and have a gradual recovery. When it comes to feeding, it’s often quality over quantity.

A picture of a child being fed by an MSF staff member in Kenama Hospital
Christiana Musa, MSF nurse from Sierra Leone, takes care of 2-year old Sheku Kamara in the intensive therapeutic feeding centre (ITFC), Hangha Hospital, Kenema District.
Peter Bräunig

Difficult cases

I am proud of how we managed some very complicated cases at the ITFC that the nurses had struggled to cope with before. Some nurses were so afraid of these cases because in the past many of these young patients would die. But we managed; we attended to them and many recovered. Difficult cases included kwashiorkor, one of the most severe forms of malnutrition, which can result in complicated skin lesions. Kwashiorkor is characterised by a child having oedema, or a swelling of every part of the body, which makes the skin very fragile. If the skin tears then it can cause wounds, and the healing of these wounds is complicated by the fact that the child is already suffering from malnutrition. A child’s body needs to be properly nourished for the wounds to heal. 

Malnourished children are also at a high risk of acute respiratory infections, which was another complicated condition treated in the hospital. And, of course, there is malaria which is the main cause of death for children under 5 years in the country. 

Malnutrition is the global underlying factor in nearly half of the deaths of children under the age of five. The critical age for malnutrition is from six months, however, children under five, adolescents, pregnant or lactating mothers, the elderly and the chronically ill are also vulnerable.

People become malnourished if they are unable to take in enough nutritious food or fully absorb the food they eat, often due to acute illnesses such as malaria, diarrhoea and pneumonia. Malnutrition can also lead to a weakened immune system, like in the case of HIV and TB, making people vulnerable to other diseases, which in turn can lead to debilitating malnutrition, thus creating a vicious cycle. 

In Kenema, MSF teams admit paediatric patients with severe acute malnutrition (SAM), a form of malnutrition that is defined by a very low body weight or kwashiorkor oedema (abnormal body fluid retention), which results in severe swelling. MSF also reaches out to the community to share information about how to prevent malnutrition and what symptoms to look out for. 

A picture of an MSF Staff member feeding a child with her mother.
Christiana Musa, MSF nurse, and the mother Mariama Kamara, give-ready-to-use therapeutic food to little Alice Tilu.
Peter Bräunig

Sharing valuable knowledge with communities

Health education plays a crucial role in the success of a hospital like ours and the recovery of our patients. Many parents are not aware about how to feed correctly their children. They might just follow the same feeding pattern that they received or saw growing up; they might not understand that while it’s okay for an adult to eat rice, the nutritional value for a child is not sufficient and can contribute to malnutrition. From the experience that I had in the year that I was in Kenema, I can honestly say that most of the problems we saw came from a lack of knowledge around childcare. 

To address this, we ran a health promotion programme for mothers and caregivers twice a day in the hospital. In the morning and afternoon, health promoters sit with the parents and share with them all the factors that could contribute to child malnutrition. They would teach them about nutrition and discuss what food is appropriate for children. The health promoters would find out what the mothers have in their homes and give advice on what and how much the children should eat. They encourage the mothers to also share what they have learnt with the rest of their community when they return home. 

It is important that the community in Kenema district first understood why malnutrition is a problem and what we were trying to do. If people don’t have the knowledge about what you are doing they won’t use your services. 

A picture of a child holding a balloon at Kenema Hospital with an MSF staff member.
Sheku Kamara, 2 years old, is treated for malnutrition, malaria and pneumonia in the intensive therapeutic feeding centre at the MSF Hangha Hospital, Kenema District, Sierra Leone
Peter Bräunig

Making an impact

What I enjoyed most is seeing the impact that MSF is having in the community. In Sierra Leone, the consequences of civil war, Ebola, cholera and Lassa fever left communities disabled and it was hard for the government to cope. MSF is able to work alongside the government health facilities to help meet the demand for quality medical care and ensure access to primary and secondary care 

MSF has worked in Sierra Leone since 1986. In 1995, MSF sent teams to provide assistance to displaced Sierra Leoneans during and immediately after the decade-long civil war and also launched a large-scale response during the West African Ebola outbreak of 2014-16. MSF currently works in three districts – Kenema, Tonkolili and Bombali and runs its own medical projects while supporting the Ministry of Health and Sanitation (MoHS) in providing primary and secondary healthcare. MSF’s current activities focus on children, pregnant and lactating mothers, TB patients and survivors of gender-based violence.