The developing world is now looking towards the Mt Frere and Sipetu communities, one of the most under-resourced regions in South Africa, for answers on how to treat severely malnourished children.

The “ten steps for recovery” protocol, designed by the World Health Organisation (WHO) has seen a dramatic drop in the mortality rate of malnourished children admitted to the Mary Theresa (Mt Frere) and Sipetu hospitals.

Severe malnutrition was identified last year by University of the Western Cape (UWC) researchers as an important cause of preventable death in the two hospitals. The work performed there supported literature which shows that many deaths occur as a result of outdated clinical practices and that improving these practices reduces fatality rates.

Before the project started last year, Sipetu had a fatality rate of 28%, while at Mary Theresa hospital it was 38%. With the ten step programme these numbers have been halved.

Other constraints such as shortage of space and staff also contributed to the high death rate.

“The children were dying like flies,” said Nomthandazo Mdingazwe, the nurse in charge of Sipetu’s paediatric ward.

Mothers at Sipetu Hospital are as much involved in the hospital care of their children as the nurses and doctors. They are called on to feed and bath their children and participate in monitoring their progress

“There were huge staff shortages at night. You resuscitate a child if there is time, otherwise you just console the mother,” she said.

Naniwe Matinise, paediatric sister at Mary Teresa, identified previous constraints as the fact that they had to wait as long as two weeks for test results, nurses using outdated practices and poor recording of patients.

A recent review worldwide found that many health services used discredited practices and that staff were unfamiliar with modern, effective guidelines for the management of severe malnutrition.

Inappropriate practices that often resulted in death included overuse of intravenous fluids for rehydration, inadequate feeding leading to hypoglycemia and hypothermia, untreated infections and failure to correct electrolyte and micronutrient deficiencies.

A youngster is weighed at the Under Fives Clinic at Sipetu Hospital. The nurses and mothers are being trained to identify malnutrition at an earlier stage by recording the child’s weight and growth on a regular basis.

Researchers also found that slow recovery among survivors was associated with a lack of energy and nutrients necessary for rapid catch-up growth.

The WHO guidelines for routine treatment consists of the 10 steps together with prescriptive actions. The ten essential steps are:

1. Treat/prevent hypoglycemia (low blood sugar);
2. Treat/prevent hypothermia (low body temperature);
3. Treat/prevent dehydration (loss of body fluids);
4. Correct imbalance of electrolytes (salts in blood and cells);
5. Treat infections;
6. Correct deficiencies of micro-nutrients (vitamins and minerals);
7. Start cautious feeding, then
8. Rebuild wasted tissues (catch-up growth);
9. Provide stimulation, play and loving care;
10. Prepare for follow-up after hospital discharge.

“This study has shown that hospital staff, even in the most under-resourced areas, have the ability to identify and begin to rectify poor practices,” said Dr Thandi Puoane of UWC.

Although it is still early days, government has welcomed the findings, indicating that the programme will be replicated in other areas.

“I am very impressed and encouraged by what I’ve seen,” said Dianne Kloka, assistant director for nutrition at the Department of Health.

“Especially because what I have seen is in a rural area.”

She identified the critical success factors of the project as:

• the involvement of other sectors in the community (social workers);
• the fact that the project started small and was already making an impact;
• the user-friendly protocol (10 steps);
• the participative research (UWC and Initiative for Sub-district Support);
• support of management (hospital);
• commitment by the staff (Nurses and doctors).

UWC Professor David Sanders said malnutrition resulted from the failure of many sectors and that the Integrated Nutrition Programme was a very complicated programme to implement.

“If successful it will solve a lot of other health problems such as diarrhoea and tuberculosis. We can save a lot of children by changing our practices and fortunately we now know what should be done,” he said.

To help develop a functional district health system, the Initiative for Sub-District Support and the Public Health Programme of UWC are now working in collaboration with the Eastern Cape Department of Health to develop a model district-based Integrated Nutrition Programme which would involve people working in other sectors such as education, agriculture and the environment. ‘€“

Health-e news service [Published in City Press 14/11/99]