Improv and starvation - A patient encounter on Good Sheppard Hospital's malnutrition ward

Good Sheppard Hospital's pediatric ward.

A 22 month-old child should not be able to fit into a newborn’s clothing, and a 22 month-old should not weigh 6.6kg.

Of course, no child approaching two years of age should have HIV (it is after all, preventable), but this 6.6kg 22 month-old did.

His name was Zaba.

I met this slight child while on rounds in the malnutrition ward at the Good Sheppard Hospital in Siteki, a small town in the rural Lebombo region of Swaziland. True to it’s name, the Good Sheppard Hospital watches over children like Zaba, and does it well.

GSH also sets an example as to how a malnutrition ward can and should work. I traveled there last Wednesday with a small group from Mbabane Government Hospital.

MGH’s malnutrition ward does not currently work.

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The visit left me with the impression that a feeding ward is not that complicated, at least conceptually. Consider these basic steps:

Step 1: Take a child that is starving.
Step 2: Make some milk-based formula with an appropriate* amount of sugar, fat and protein.
Step 3: Feed the starving child an appropriate* amount of the formula very three hours.
Step 4: Treat any ongoing infections that are affecting the child’s nutrition.
Step 5: Once the child stabilizes (i.e. graduates from a starving child’s metabolism and the dangers inherent in it--low body temperatures, fluctuating electrolytes, etc), feed a bit more.
Step 6: Once the child is only 2 standard deviations skinny (rather than >>3), send the child back home on a appropriate diet of formula or breastmilk.
Step 7: Weigh the child every so often thereafter.

*“Appropriateness” has been well-studied and is dictated by World Health Organization reference tables.

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Zaba was in the midst of step five.

The clipboard at the foot of the bed told a story of a sickly child, HIV positive, who had been at home starving for much of his life. The mother, HIV positive herself, weaned the child from breastmilk at 6 months, as instructed by her local health worker. (Current recommendations advise this for it limits HIV transmission via breastmilk.)

Since weaning, Zaba has not done well. On the clipboard's pages, the words "diarrhea" and "weight loss" repeated themselves time and time again, page after page, the mantra of a child approaching an early death.

I noticed Zaba among the others because he looked at me for a long time, and did so with big, calm eyes. His was a piercing but effortless stare, the kind I am used to getting from twenty-something-month-olds, but without the usual component of curiosity and fear.

I am not sure why, but with time I began to sincerely believe that the child knew something that I did not know, some important secret.

As the physician heading rounds continued teaching us about malnutrition, I realized that there were many things about starving children I did not know. (I will describe my ignorance in more detail in my next entry, to be posted tomorrow or the next day.)

Zaba was wearing small powder blue pants with a cartoon-like puppy sewn into the right leg. The folds in the petite but baggy pants were such that I am not entirely sure that the animal was actually a puppy, but that was my impression. In any case, it was a cartoon-like animal.

The bitty child’s diminutive white shirt was the same variety issued to newborns in US nurseries, the soft, cotton type with a large collar for the relatively large neonatal head.

Zaba’s head was still relatively large, his body still not catching up. His narrow neck, jutting from the large oval collar, accentuated the disproportion.

He had the habit of tilting his chin up slightly, as if turning his nose up at something. As a result, his heavy head seemed to be awkwardly balanced on the thin, slanted neck below it, like a golf ball on a crooked tee.

This did not influence his gaze, which rested squarely on me.

As we were completing our discussion of Zaba’s progress (he was gaining wt, now a mere 1.4kg short of his weight goal), the GSH pediatrician asked Zaba’s mother how the feeding was going.

She answered in Siswati.

“He’s eating like a pig,” was the translation.

More Siswati.

“Mom is asking for more milk.”

The volume of formula was increased, and we walked over to the next gurney. It was next to an open window.

The window overlooked the lowlands of Lebombo. The air in Lebombo is hot, the land dry, and the people poor. The dirt in this part of Swaziland is iron-rich, similar to the soil on the banks of the Red River in north Texas where I grew up.

The scattered fields of brown maize were pretty against the rusty soil. The crops were shaped like puzzle pieces, evidence of Swaziland’s improvisational approach to agriculture.

It has been a dry rainy season.