Benoit Fick/MSF

Benoit Fick/MSF

Views ........................................................................

“There are MAMs,
then there are MAMs”

A young girl has her
MUAC measured at an
MSF outpatient clinic
in Northeast Nigeria,May 2018

By Kirrily de Polnay
Kirrily de Polnay is a Nutrition Adviser for MSF based in Brussels and is leader of the MSF
Nutrtion Working Group. She is a medical doctor by training, with a background in
paediatrics. She previously worked in the ﬁeld with MSF and at the Institute of TropicalMedicine in Antwerp before returning to MSF in a headquarters role in 2016.

Five expectant faces are staring at me,waiting for me to answer the question.
“Well,” I start, “ere are MAMs, andthen there are MAMs”. Five expectant
faces show a variety of frowning, nervous smiles
and confused expressions.
I am standing in our inpatient nutrition ward
in a hospital in Masisi, Democratic Republic ofCongo. e five expectant faces are two doctors,
two nurses and a nutrition assistant – we aredoing the morning ward round together. Once
we have all established, yes, I meant to say that,
it wasn’t my bad French, I try my best to explain.
The question they asked me is one of a suiteof questions I get asked by many of our projects
in many different countries and continents:‘How should we treat the children with moderateacute malnutrition (MAM) with medical complications who need hospitalisation – do wetreat them as if they were suffering from severe
acute malnutrition (SAM)? Do we put themthrough the whole nutritional treatment protocol, starting with F-75 onwards? Do we referthem to outpatient therapeutic feeding programme (OTP) nutritional care when they exit
the hospital?’
At Médecins Sans Frontières (MSF), praticallyall of our projects are implemented directly by
MSF doctors, nurses, midwives, pharmacists,psychologists, etc., working on the ground,whether with ministry of health staﬀ or in ourown projects. We try to equip our staﬀ to deal
with the many diﬀerent contexts and medicalconditions with which they will be confronted
through medical protocols and guidelines thattake into account the latest evidence, combinedwith our communal clinical experience. Wethen try to support them through field visits,
calls, skypes and emails to make sure that these
protocols are achieving the quality of patientcare that we all aspire to.
One of the biggest goals of this approach isto provide guidance for clinicians with diﬀeringlevels of clinical experience and expertise, fromthe community health oﬃcer in Sierra Leone
who is now working in our paediatric intensive
care unit with only three years of medical education, to the first mission doctor who has ten
years of experience in Europe, but has neverseen a malnourished child.
We don’t always have the luxury of experienced
clinicians who can take our protocols, but thenuse their own knowledge and experience toadapt treatment to each specific patient. is isespecially the case for children with MAM withmedical complications who need inpatient treatment. Complications may include shock, alteredstate of consciousness (coma, lethargy, drowsiness), seizures, pneumonia, diarrhoea with severe
dehydration or bloody diarrhoea, severe anaemia,
severe malaria, other severe infections (e.g.,meningitis), severe skin condititions and con-genital malformations leading to feeding diﬃculties, among others.
e most common approach in MSF has
been to treat these children the same as those
suﬀering from SAM, providing the same medical
and nutritional treatment.
Indeed, this was the approach that I followed
as a field doctor when I started with MSF in
2011. I was very new to seeing malnutrition;
my training in south London had actually
exposed me to advanced tuberculosis, HIV andeven rickets in children, but treating kwashiorkor
and other aspects of malnutrition was a hugelearning curve. Even then, I had concerns as towhether this was the right thing to do for all ofthese children, but there were no strong international recommendations that were diﬀerent
to MSF’s.
e more time that I have spent caring for
malnourished children, both in the field andnow from headquarters, still giving clinical input
into individual cases as well as working on theaforementioned protocols and guidelines, themore complicated I see the ‘MAMs with medicalcomplications’.
One of the main issues here is a chickenand-egg conundrum. MSF is likely to see twomain profiles of MAM with medical complications – and probably everything in between.
ere are children who come into our health.......................................................................................................................................

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Field Exchange issue 60, July 2019, www.ennonline.net/fex

ViewsHakim Khaldi/MSF................................................
facilities who are very sick, perhaps even in acoma, who may be having a seizure, who arefound to be MAM in triage. Aer 24 to 48
hours of appropriate treatment and close monitoring, these children are bright as buttons.
is Lazarus-like ability of children to recoverfrom illness quickly is why we love paediatrics
so much.
en there is the other profile. ese children
have the same presenting condition and aer
the initial 24 to 48 hours of treatment and monitoring are usually slightly better, but are mostdefinitely not bouncing around the ward. esechildren are slower to repond and may experiencesome ups and downs in their condition. egeneral feeling is that this is a vulnerable child– one we need to watch.
We have come to think that the first profile
is likely to be a child who has become severely
unwell (over a period of time that it is oenhard to determine) and then slipped into MAM.
is child likely still has the physical resources
and homeostatic buﬀers to br able to bounceback with appropriate treatment. e second
profile is likely to be a child who has been MAM
for a longer period of time, whose physiology
has had to adapt and adapt again to decreasing
resources, perhaps also suﬀering from a numberof episodes of illness. ere is then one severe
episode that pushes them over the edge; homeostasis breaks down and their bodies can nolonger cope. eir slower response to treatment,with a bumpier course, is most likely related totheir exisiting MAM.
Following this train of thinking, it would
seem logical that the first profile of children
could be treated as MAM rather than SAM; i.e.;
start them on normal food as soon as their condition is stable enough for enteral feeds (whether
initially through a naso-gastric tube or straightto oral), with supplementation such as a readyto-use-supplementary food. Indeed, as I started
children with this profile on the full nutritional
protocol with F-75 in my early experiences inthe field, I worried they were not getting enoughcalories or protein to help fight their infection.
Furthermore, these children were hungry! It isChildren being screened at atargeted food distribution,
Maiduguri, August 2016

hard enough when you see a SAM child cry fornormal food rather than F-75, but at least you
know that this is the best treatment we currently
have available for their condition, and thatgiving them normal home food could makethem worse through refeeding syndrome.
For the second profile of child, the one who
has likely had MAM for a long time, one canfeel more confident starting them on the full
nutritional protocol as it seems logical that theyneed a slower approach, with more attention totheir metabolic stabilisation.
More oen than not, it is extremely diﬃcult
to be able to tell if the sickness or the MAM
came first when a child first presents. Why?
ere are many reasons. For example, the history
given by the child’s caregiver may not be precise
enough to help you to work out which profile
the child fits. We oen see that caretakers may
not feel confident talking about a lack of foodat home or a diﬃcult situation that has led tothe child having less food. We also frequently
see these children brought in by their mothers,
but with a history of staying with other family
members while the mother works or studies
elsewhere. is is a stressful time for this mother.
She is unlikely to have wanted to leave her childin the first place, but it was the only way to keep
her family afloat. She may feel guilty because
the child became unwell or did not have accessto enough food, or the right kind of food, whileIgor Barbero/MSF

Fatima attempts to feed her daughter
RUTF in an MSF hospital in Pulka town,
Northeast Nigeria, May 2018

she was away. She is unlikely to be able to give aclear account of her child’s health during thetime she was not with the child.
As mentioned previously, these two profiles
are perhaps the extremes of the spectrum. eadded complication to this already-complicatedissue occurs when a child presents in between
these two extremes: it can be even more diﬃcult
to work out the best course of action. So, how
can we write a clear protocol that accounts forthis complexity and caters to clinicians with
diﬀering levels of experience and capacity? Well,
we probably haven’t come up with the rightanswer yet. What we have tried to do is to put
huge emphasis on assessing next steps of care by
the clinical response that we see when we start
treatment, close monitoring to pick up on subtle
changes in clinical condition, and discussingthese cases with our medical team. at teamstarts with the medics in the field, but extends all
the way to me in Brussels through direct emails
and calls or via our telemedicine platform.
And what about follow-up? Again, we advise
case-by-case and give our teams the autonomy
to adapt to their context, but we all know paediatricians are control freaks, so we usuallyadvise them to come back to our outpatient
clinic for follow-up, even if our outpatient programmes don’t normally admit MAMs (something else we are trying to change at MSF…)
We all grew up in medicine working in teams;
they are our support network and oen ourlifeline. With some of these diﬃcult and complex
questions regarding malnourished children, my
medical team extends beyond MSF and into
the nutrition community. I oen send out mydistress calls to clinicians I trust and respect,such as Jay Berkley and Indi Trehan. It brings
me comfort when I find them thinking along
the same lines (although they usually express it
more eloquently and with a whole bunch of papers for me to read to back it up!). It is also a
comfort to know that there is great research inprogress, such as Mark Manary’s high-MAM
tudy in Sierra Leone. Hopefully, we will soon
be able to provide better guidance to our cliniciansin the field and deliver the best possible care tothese little ones with MAM.
For more information please contact Kirrily de
Polnay at kirrily.de.polnay@brusselsmsf.org.......................................................................................................................................

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Field Exchange issue 60, July 2019, www.ennonline.net/fex