Luigi Greco, Jacquie Belungi , Kevin Amodu , Robert Iriso and Bruno Corrado
St Mary’s Hospital, Lacor, P.O. Box 180, Gulu, Uganda
To evaluate the feasibility and the efficacy of the introduction of a nutritional supplement made by traditional foods in a population of severely malnourished children.
Population and procedures
At St Mary’s Hospital Lacor, as in most african hospital, half of the patients are children affected by common infectious diseases. Malnutrition is, by itself, the first cause of fatality , but it also underlies a significant proportion of the fatalities due to common infections.
The Nutritional Unit is the typical service for malnourished children available throught Africa : a special ward, independent from the children’s ward, to which severely malnourished and extremely ill cases are transferred . This ward is managed by a clinical officer and very skilled nurses.
Criteria for admission to the Nutritional Unit : children aged 6 months to 6 years affected by severe malnutrition, with a weight 75% below that expected for height (marasmic cases) , or peripheral oedema scored 1 to 4 + (kwashorkior cases) . A third group shows both conditions (underweight and oedema).
Nutritional intervention from unicef
The reason to set up Nutritional Units through Africa is the availability of a nutritional rehabilitation intervention, based on the Modified Cow’s Milk F75 (starter) and F100 (follow up) supplied by UNICEF.
These milks are given, in proportion of the body weight , at 3 hourly intervals.
Childrens unable to drink are fed by plastic siringes and nasogastric tube. The theoretical daily supply of energy is 140 to 200 Calories/kg body weight. But this amount is very difficult to admnister to any single child. Nights feeds are generaly not available.
Table I shows the composition of the two milk feeds : F75 starter, to be given for the first few days, and F100 for follow up. From the table is clear that the feeds are based on skimmed milk with added sugar and vegetable oil.
From the clinical observation of diarrhoea following milk ingestion in some cases, we suspected that some severely ill children could not fully absorb the energy provided by the milk containing full lactose and sugar.
Rationale to evaluate a new nutritional intervention
The fatality rate observed at Lacor in the malnourished group , above 20%, is 3 to 4 times higher of that expected after nutritional rehabilitation in similar units in Africa (1)
The analysis of the individual weight growth curves , from cases admitted in the months of June and July 2002, before this intervention, did not show in most cases the expected catch up growth, after the nutritional rehabilitation based upon UNICEF milk. Finally a significant proportion (8-10%) of mothers ‘escape’ , often because of discouraging results.
According to WHO reccommendations (1), we proposed to evaluate the possibility to introduce a new nutritional intervention, to be added to the UNICEF milk, for the following reasons :
• Actual results of the nutritional rehabilitation with the UNICEF milk are discouraging
• The large amount of lactose and sugar of these milks might facilitate diarrhoea, malabsorption and fatality
• The UNICEF milk, as any other powdered milk, is not available outside the hospital : many children do relapse , because they are poorly fed when the milk is interrupted by the discharge from the hospital
• Milk feeds are not available and not traditional to the Acioli children
New nutritional intervention started august 1st 2002
Following the observation of the traditional feeding habitus of the Acioli people, and a further check of the availability of the food items at the local market, we purchased at the market outside the hospital maize flour , rice, millet, peas and beans, peanuts , small dry fishes, cow’s meat, chicken and vegetable oil.
We prepared a thick semi-solid porridge , with a cereal flour base as carbohidrates, proteins (fish, legumes, meats on rotation ) and fats (peanut butter and vegetable oil). The porridge was named NUTRICAM (in the local language, Acioli, means nutritional feed) .
Table II shows the composition and the cost for one serving: two servings are given to each child per day. Table III shows the week rotation of the feeds, in order to provide for different sources of proteins. 100 child/day/servings are prepared each morning and 100 each afternoon. A single daily feed (two servings) for a child costs about 5,9 cents of Euro. The total monthly cost, including ingredients, fuel and salariy for the cook is about 220 Euros. (Table IV). Table IV shows the cost of the milk feeds for the same 100 children and the ratio Nutricam/milk cost.
Short tern results
The 96 children admitted from the 1 st to 31 August 2002 were the study sample, while the 94 admitted in the month of July were the control group. Both received three hourly the UNICEF milk according to reccommendations, the study group received, in addition, the Nutricam supplementary food in 2 servings of 200 gr per day.
Measure of outcome
After the distribution of the NUTRICAM, each child was surveilled for his ability to eat the porridge and for the presence of vomiting or diarrhoea. Mother’s attitude towards this feed was observed.
Children weight was measured to the nearest ten grams every two days by accurate beam scales. In order to standardize for the status at admission (underweight or oedema or both) , we computed the increments in the underweight cases as plain difference from the weight-at-admission, while in the severe oedematous cases (oedema rated at 2+ or more) we computed the initial loss of weight as 50% of positive increment and to this we added as positive the increments observed from the nadir of the weight, when oedema disappeared (for example an oedematous child of 3 years weighed 13000 grams on admission with oedema 4+ , he lost 2 kg in the first 10 days , reaching the minimum (nadir) of 11000 grams, then he grew 700 grams in the following 15 days : the total increment was 50% of the initial weight loss = 1kg + all the ‘real’ growth thereafter + 700 = total 1700 grams.
The NUTRICAM feed has been accepted with enthusiasm by the local population and by the children. They completely consumed two servings each day, while not interrupting the milk feed. We could not observe adverse reactions , as vomiting, diarrhoea, food intolerance. The children with severe oedema lost rapidly weight at an average rate of – 32 grams/day. The severe underweight cases showed a rapid catch up growth at an average rate of + 36 grams/day.
Fig 1 shows the tipical weight profile of two cases admitted on mid July, who received two weeks of UNICEF milk, followed by the addition of two more weeks in August with NUTRICAM. Fig. 2 shows the overall weight increments standardized (by ANOVA and REGRESSION) for weight at admission, age, sex and peripheral oedema . The 94 children fed during the month of July (with UNICEF milk) compared to the 96 cases fed in August (with added NUTRICAM).
Cases are grouped according to their starting condition :
July : 43 Underweight , 34 Oedematous and 19 Underweight with Oedema = 94
August : 44 Underweight, 30 Oedematous and 22 Underweight with Oedema = 96
Children fed in August received obviously more calories than children fed in July, but these did received already (theoretically) a sufficient supply of energy.
The cases fed NUTRICAM showed an average body weight increment about double of that observed for the cases fed the milk only.
Long term results
From January 2002 to December 2003 monthly statistics at the Nutrition Unit have been accurately recorded : i.e. : N. of admissions, N. of deaths, N. of cases dismissed ‘cured’ and N. of failures (children brought away by parents, named ‘escape’.) The Nutricam intervention started The first of August 2002.
Fig. 3 shows the number and the trend of outcome as a percentage of cases admitted each month. The top line shows the % cases dismissed as ‘cured’ : moves from 44,1% in Jan 2002 to 81,6% in Dec 2003. The lower two lines show the trends for % death and % escape : reading on the scale on the left , these percentages might be summed as overall failures : they move from 42,2 % in Jan 2002 to 18,37% in Dec 2003. Out of these we had a 22,2% fatality rate in Jan 2002 versus a 7,1% fatality rate in Dec 2003.
To evaluate the mean growth increments before and after the Nutricam intervention, to avoid seasonal effects, we randomly sampled 100 case files dismissed in the months October, November and December in the years 2001, 2002, 2003. For each case we reported the length of stay in the unit and the weight gain reached at discharge. To avoid complications with oedematous children, we have computed for all cases with oedema > 1+ , the increment between the lowest weight reached and the weight at discharge.
Fig. 4 shows the mean duration of stay at the unit and the mean weight gain . It might be noted that there was no modification of the days in care over the three years , while the weight increments almost doubled in the first year from 496grams in 2001 to 798 grams in 2002, while in 2003 the mean weight gain reached 1310 grams, for the same duration of nutritional care.
The NUTRICAM feed supplement is locally feasible at low cost (about 0,06 Euro/child serving, including labour) , very well accepted by the local dwellers, simple to prepare and very effective for the nutritional rehabilitation.
NUTRICAM does not contain lactose or other simple sugars (as sucrose), but is made up by complex starches , animal as well as vegetal proteins, mono and poli unsatured fats. NUTRICAM is not intended to supply the daily energy requirements, but is well suited to be added to mother’s milk and mixed with the other family foods. The cost of NUTRICAM is about 8% of the actual cost of UNICEF milk.
The nutritional intervention is not persistent if it is not handed to the mother’s responsability, in order to transfer this attitude to the daily village life.
To comply with this priority need, we reinforced the locally available health education activity : every other day a trained Health Education Nurse give classes in Acioli . Inasmuch the mothers, in small groups, are actually directly involved in the preparation of the NUTRICAM : they prepare, by traditional procedures, the peanuts , legumes and cereals and attend to the cooking. Four small charcoal kitchens have been set up by the hospital management , in order to facilitate the direct preparation of the food by the mothers themselves.
This nutritional intervention required no special project, no international support and a single man action at an extremely low cost (about 220 Euro/month for the entire action).
This nutritional intervention has been completely took over by the local hospital management , who does guarantee the continuation of the activity.
We believe that this experience does reinforce the nutritional reccommendations given by the International Agencies and stimulate the extention of this and similar experience in all nutritional units in the developing world.
1. W.H.O. Management of the child with a serious infection or severe malnutrition. IMCI. WHO/FCH/CAH/00.1 , 2000.
2. UNICEF At a glance . Uganda Emergency Donor Alert 22nd November 2003
Effect of a Low-Cost Food on the Recovery and Death Rate of Malnourished Children Journal of Pediatric Gastroenterology and Nutrition, 43:512-517 October 2006 Lippincott Williams & Wilkins, Philadelphia
Low-cost, local food supplement improves efficacy of treatment for malnourishment
Nature clinical practice,Gastroenterology and Hepatologyjanuary 2007, vol 4 , n.1