Many of them went through the most miserable period of their lives, under LTTE captivity, surviving under trees and in bunkers. They were in extreme physical and mental anguish, deprived of food and water, food supplies having been cut off by the LTTE.
Rice kunjee was their main food for weeks. Some had suffered longstanding diarrhoea, fevers and skin infections and had not had any medical treatment.
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| Dr. Vasana Kiridana |
Among the thousands escaping from the clutches of the LTTE in the last days of the war, were extremely malnourished children who are now receiving special treatment at the therapeutic feeding centre attached to the paediatric ward of the General Hospital, Vavuniya. At least 20 per cent of the nearly 300,000 internally displaced in the north are children.
And among the many medical and non-medical problems affecting them, acute malnutrition due to severe starvation has been identified as a major health concern. A significant proportion of these children require in-hospital care with meticulous monitoring and feeding to save their fragile lives.
Severe malnutrition is one of the major killers of under-fives in developing countries. Acute severe malnutrition is considered a medical emergency with the mortality rate (death rate) as high as 50%. These children require round the clock care, because they do not respond to medical treatment in the same way as they would if they were well nourished. Malnourished children are much more likely to die than their well nourished counterparts.
How do we identify this vulnerable group of children? All children less than five years who are admitted to the Paediatric Ward of Vavuniya General Hospital are screened for their nutritional status and the malnourished children are then enrolled in the nutritional rehabilitation programme. The most extreme cases are admitted to the therapeutic feeding centre for in-patient treatment.
This nutritional rehabilitation programme was commenced by the Ministry of Health in collaboration with UNICEF.
Due to prolonged starvation, these children have lost the ability to digest and absorb ordinary food. Their natural body metabolism is grossly altered as a result of the deficiency of major and minor nutrients. This may not be visible and often is the consequence of multiple silent infections. They can suffer from low body temperature and extremely low blood sugar. These extremely ill, fragile patients are urgently attended to and undergo careful stabilization to restore their cellular machinery and body metabolism. They cannot be fed straight away. They have lost the ability to digest and absorb food due to prolonged starvation. Some children have leg swelling and a peeling fragile skin which resembles severe burns needing special care. These children are managed according to WHO guidelines on the management of acute severe malnutrition.
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| Refugees escaping from the clutches of the LTTE to government held areas |
During the initial phase of stabilization, doctors aim to achieve normal blood sugar levels, normal body temperature, normal cellular metabolism and adequate hydration. Infections are treated with antibiotics. Hydration is carried out by drinking using a special rehydrating solution like "Jeevani" but with a different composition. Feeding is also commenced simultaneously with a special starter formula which is a medicine more than food. It takes about 5 - 7 days to stabilize the child depending on individual factors.
Once their body metabolism is restored and initial stabilization is accomplished, they are started on another formula which is specially formulated to achieve weight gain. Gradually, their appetite returns, swellings subside and a rewarding smile appears on their faces. Feeding is continued every two hours- day and night. Mothers who are breast feeding babies less than one year old are encouraged to continue breastfeeding in between therapeutic feeds. Milk is prepared hygienically in the kitchen adjacent to the feeding centre. This entire feeding programme is a very tedious and time consuming process.
At this stage older children are ready to eat. They can sit up and interact with the environment. They are then offered semi-solid and solid food, again which is specially prepared and ready to use. Their feed volumes as well as energy consumption are gradually increased. They are weighed every day and the weight gain is calculated and recorded. Once a satisfactory weight gain is achieved the patient is ready to be discharged from the therapeutic feeding centre.
Along with the therapeutic nutritional rehabilitation, sensory stimulation and emotional support should go hand in hand. When we first see the children, they appear very lethargic and apathetic, with no smile, no interaction with their surroundings. They have no energy to walk or run around. As they improve in our care, it is very rewarding to see them looking around, getting interested in the world around them, smiling and starting to walk. This is no miracle, it is achieved by the commitment and care of people with heart - doctors, nurses, student nurses and feeding assistants who work day and night dedicatedly to treat, feed and care for these fragile children.
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| A malnourished child at the paediatric ward of the General Hospital, Vavuniya. |
On our way to success, we face numerous problems. Inadequacy of staff to feed, monitor and look after these kids is one of the main problems which directly affects the smooth functioning of the unit. Sometimes parents are not keen to keep the child in the therapeutic feeding centre for several reasons - one or both parents may have a medical or a surgical problem which becomes a priority over the child's malnutrition.
Leaving other children or a handicapped family member in the IDP camp can become a problem. Parents also try to feed other accompanying children with the nutritional supplements offered to the malnourished child. Parents have to be educated that these supplements are medicines, not food to be shared.
The IDPs have received generous donations from all over the country. But sadly these poor children are suffering without adequate clothes and toys which is an essential part in their management. Overcoming the difficulties and facing all challenges, we are making our way forward because we consider this an added value to our service, not a burden. |
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