What you need to know:
- Malnutrition causes nearly half of all deaths of children under five years globally
- When the body lacks food, Dr Ngwiri explained, it misses its main source of energy, called glucose
- If this energy is not replenished, organs weaken, they stop working
- Although there are many different types of RUTFs, the most popular one is Plumpy’nut
- Unicef procures 90 per cent of Plumpy’nut
When they were wheeled into Kapenguria County Referral Hospital in West Pokot, twins Joy and Rael Mukhwana were too weak to even cry.
The nutritionist in the hospital’s paediatric ward, Miriam Cherop, said the nurses and the doctors categorised them as suffering from severe acute malnutrition — children deprived of food so much that their organs were almost shutting down.
“At nine months, they weighed two kilogrammes when their peers at that age weighed 10kg. They had not reached milestones like seating or crawling,” Miriam told HealthyNation.
Through a combination of medical care and, perhaps the blessings of mother nature, the twins improved and walked out of the jaws of death in the three months they were in the hospital. In those three months, there were days the twins were so sick that they had to be put on a ventilator.
In August this year, they weighed 4.8kg and were discharged.
Apart from the medical interventions that gave the twins a second chance at life, there was another miracle: ready-to-use therapeutic foods (RUTFs). One particular brand, popularly known as Plumpy’nut, saved the twins.
According to the Health ministry, more than 370,000 children aged between six months and five years, and 78,328 pregnant and breastfeeding mothers need the RUTFs desperately.
But, Plumpy’nut is now in short supply in Kenyan hospitals.
Health Principal Secretary Susan Mochache said the shortage of the life-saving medical product is due to Kenya’s reclassification as a low middle-income country in 2014. It was previously classified as a low-income country. This new status meant the country was capable of purchasing some life-saving products such as Plumpy’nut and, as a result, donors withdrew their support.
Dr Thomas Ngwiri, a paediatrician and the head of clinical services at Gertrude’s Hospital in Nairobi, has treated many children with malnutrition and said lack of food was not the only problem.
“Sometimes children born to very young mothers, who do not know how to feed them, could be the cause or some diseases such as tuberculosis, which make children lose appetite,” said Dr Ngwiri.
RUTFs such as Plumpy’nut, F75 and F100 are to severely malnourished children what antibiotics are to adults with pneumonia, and their stockouts lead to the deaths of many children under five.
The World Health Organization reports that malnutrition causes nearly half of all deaths of children under five years globally as their immunities cannot fight the communicable diseases. The number of children with severe acute malnutrition increased from less than 50,000 to more than 370,000.
Although there are many different types of RUTFs, the most popular one is Plumpy’nut, a sweet-tasting paste made of peanuts. The paste has lots of calories and vitamins that scientists have made to nourish starving children.
Unaware of the clinical complexity of starvation, governments often dispatch maize and flour to families during famine and the food ends up killing the children. This is because while the lack of food induces severe malnutrition, the food becomes poisonous when served in that form.
When the body lacks food, Dr Ngwiri explained, it misses its main source of energy, called glucose, and to survive, it begins breaking down stored fat into energy and chemicals called ketones. However, the brain and red blood cells cannot use the ketones, so they turn to the muscle and break it down to get energy. When the body is completely drained of fat, the babies also die of cold (hypothermia).
“At this point, the little energy left is channelled to the vital organs such as the brain, but the children are extremely vulnerable to other diseases, which could kill them,” he added.
If this energy is not replenished, organs weaken, they stop working and the child eventually dies from organ failure and other complications. At this point, ordinary food can kill the baby through “refeeding syndrome” as the organs are too weak to digest food and will collapse, Dr Ngwiri explained. That is why doctors and nutritionists prescribe RTUFs.
Veronica Kirogo, the head of the nutrition division at the Health ministry, said 92g of the paste had as much as 500 kilocalories and caused children to add pounds rapidly, often going from a near-death state to relative health in less than a month.
Public hospitals, where the majority of children and mothers that are severely malnourished seek treatment, do not have enough stock. Hospitals in arid and semi-arid counties suffer the most due to this shortage. These include Baringo, Garissa, Isiolo, Mandera, Marsabit, Samburu, Tana River, Turkana and Wajir. The semi-arid counties hit hardest are Embu, Kajiado, Kilifi, Kitui, Kwale, Laikipia, Lamu, Makueni, Meru, Narok, Nyeri, Taita-Taveta, Tharaka-Nithi and West Pokot.
The Health ministry has since listed the RTUFs as part of essential medicine. The Health PS said the ministry has petitioned the Treasury to allocate money for the foods, but even that would not be enough because the solution to the shortage is a political, financial and logistical challenge on the local and international front.
Globally, Unicef procures 90 per cent of Plumpy’nut, and supplies it to health facilities in Kenya at the cost about Sh5,000 until the child is nourished back to health. Ironically, although assembled from local foods such as groundnuts, RUTFs are way cheaper when imported than when assembled locally.
Nutriset, the French company that made Plumpy’nut, has faced challenges with people fighting for the patent. The company told HealthyNation it has an official distributor based in Kenya, Techno Relief. Bertrand Guillemot, Nutriset’s head of communication, told HealthyNation the company had “has stocks of our products to support emergency programmes in East Africa”.
Few health workers
Even when it is available, administration of Plumpy’nut needs nurses and a physical structure, two necessities that counties such as West Pokot, which need the RUTF, lack.
According to the 2014 Kenya Demographics Health Survey, West Pokot had the highest rate of undernutrition in the country at 46 per cent of all children under five years. The numbers reduced to 35 per cent as of last year, but the WHO still classifies it as “very high”.
In Nang’olesinyon, North Pokot, Esther Mark walks more than 15km on the sun baked soil in the sweltering heat to get to a small semi-permanent house with her children for immunisation. At the centre, there are more than 100 mothers, sometimes each with more than four children seeking vaccination. Esther said she was grateful for the centre, but would like a little more. “I wish we could have a stable hospital because this is a church and sometimes a school, so we feel like we disturb the children,” she said.
Sadly, while the centre is very helpful, the support that purchases the RUTFs comes from an international NGO, Action Against Hunger. It is in these clinics where the nurses pick the severely malnourished children.
Winzer Kirui, a public health officer in West Pokot’s Kiwawa ward, who runs these outreach clinics told HealthyNation that they pick up children who need hospitalisation, but sometimes fail to due to the shortage of the RUTFs. Another problem they face is the shortage of healthcare workers who can screen and administer the RUTFs. “If we could have more nurses, it would really help,” he said.
The county’s nutrition department worries that due to the shortage of the foods and the other challenges, the children who had moderate acute malnutrition were at risk of moving to the severe type.