Feeding Babies

Daily I do rounds in Paediatrics, see the small babies in Maternity and then do sick rounds in “Nutrition, a feeding station for outpatient malnutrition patients. Twice a week I see all 3 dozen patients or so for evaluation of their progress.

Feeding stations are a staple of mission hospitals, either free-standing or in cooperation with the government as this one is. Mothers are admitted with all their children for supplemental feedings, lessons on food production and general child health like immunizations, malaria prevention and safe water tasks. One may not notice this at first as these tasks take place under the filtered light of locust trees in an area around an open-air tin-roofed affair. The furnishings are low benches, tables and the concrete floor. Across one wall, hand-drawn pictures illustrate fruits, vegetables and cereals (red millet is the favorite, known locally as “guinea corn”). Murals on the half-walls illustrate a market scene. A fortified room with heavy padlocks houses the supplemental food, sporting “A gift from America” and “NOT for resale.”

The give-away to the feeding station are the mats stretched out among the trees and the scrupulously swept dirt each morning.

Much of this belies the sophistication of the work being done. The subsistence farmers will do well during the wet season but slip into starvation during the “dry.” The diet contracts to merely millet and taro root; both of which tend to make malnutrition worse as they prevent absorption of some nutrients. Children, particularly after they are weaned are at special risk. Children do well until they are introduced to solid foods at about 5-6 months. It is only then that a fat infant starts a cycle of a relatively minor infections, a period of weight loss, a small rise and then another failure. It is not uncommon to see a child lose weight from 5 to 14 months, weighing 12 lbs when identified.

Their diet is “koko” or “tizit,” essentially millet porridge or gruel respectively. Considering that a child then is a greater risk for contracting malaria, typhoid and parasites compared to an adult, it is not hard to imagine such a one “being knocked off the wall” and sliding in to marasmus or kwashiorkor. The first is total nutritional deprivation with muscle wasting and the look of the aged in the eyes of a 9-month old. A stethoscope cannot find enough tissue between the ribs to make listening easy.

Kwashiorkor is a protein malnutrition with the pot-belly, swollen legs, red hair and pale skin of numerous “poster children” for famine of the last 50 years. These have to be treated with caution as rapid re-feeding is associated with sudden death as malnourished hearts try to accommodate the changes. These children in particular need a “complete” protein. No vegetarian protein source is “complete” for human infants. Each by itself would gradually produce protein deficiency.

The answer is remarkable. The Nutrition station makes its own variety of “koko” (porridge) from millet (very much tastier than maize) and soy beans. The right proportions are coarsely ground in a wooden mortar, retaining the husk of the millet, (which is usually removed my soaking otherwise). The coarse grounds are lightly roasted and and then finely ground to a flour. I exaggerate in no way by saying this stuff is good! It produces a porridge with complementary proteins from the two sources, very much closer to an “complete” protein.

I go over all the weight curves and treat all the acute malarias, pneumonias, typhoids and such of the “well” kids; admit the 4 or 5 who need to be hospitalized for the same problems and admit the 3 or 4 who have finally “failed” in a bid to gain weight. These may die in hospital from their malnutrition. They of course, die of some disease like malaria or meningitis but the bottom line is that they arrived at death’s door merely from starvation, the “intercurrent” disease merely ushers them through.

I frequently hear travelers who come home complaining that the unsophistocated natives of the “third” world imagine that all Americans are rich. Considering never fearing starvation as a measure of immense wealth, I wonder who the naïve one is.

Empty Spaces

I was called at 4:15 on Monday morning; the “well” preemie in maternity was having respiratory distress and the midwife had started oxygen. I pulled on same scrubs, strapped on my “fanny pack” filled with my medical tools, a couple of books, a hand-sanitizer, insect repellant and a small camera and walked up the hospital. The ‘hamartan” was blowing briskly, the moon was up and the road was easily visible until it got under the drought-stripped locusts. The drums which I had heard at sun-down continued now; a local chief had died and the “death house” was a scant couple of miles over the next ridge east of here. The creaky-gate call of a solitary fruit bat ticked off one per second. I didn’t bother with my “torch” for the quarter mile walk.

I met and passed a few Ghanaians’ with a polite “najanuri….naaah” formula (good evening…. *acknowledgement*) and crossed over into the maze of concrete steps and ramps which is the sign of a rural hospital in Africa. Electricity is never taken for granted and all areas can be reached by gurney and muscle- power. I turned down to maternity and into the nurses’ station to find my 5 day old patient. He was vigorous and feeding well by cup just this afternoon.

He really did look sick. He was breathing fast, pulling in between the ribs as he did so. His heart tripping along at almost 200 beats a minute. I washed my hands and started to examine him; involuntarily pulling my hand back as I started. He was HOT. The reason became apparent. The ancient incubator had two settings: “Off” and “On”. The nurses, taking counsel of their own discomfort at the cool weather had turned on the heat and left it on. The baby’s temp was 38.5C, about 102.7 or about 5 degrees Fahrenheit higher than it should ever have reached. I had the heat off and the incubator lid opened. Wrote some instructions about measuring the infant’s temperature to determine his care and went to see my other little patient who was on the ward. He looked no worse than he had that evening, warm but having some trouble breathing himself. I adjusted his position, replaced a water bottle and went back to the house.

At 5:15 I was called that my baby on the ward “had stopped breathing.” Something is usually lost in the translation of course, as the messengers are merely ward workers and not nursing staff. I asked if this meant he had died; a blank stare and a shrug was the answer as they turned back into the darkness. I followed them shortly, and arrived ahead of my own orders.

The reality was rather closer than I wanted. He was gasping again, heart rate (again) in the 60’s, pale cold blue and dead looking. I called for the breathing bag (the hospital has one for infants) and started to stimulate him to breathe (a maneuver which is not likely to work without the bag). He gasped and gave a squeaky breathe. Looking more carefully, with my “torch” I could see he was not breathing through his nostrils as they were completely obstructed with dried mucous. I cleared a bit away, got the bag and started to breathe for him. His heart rate once more responded. The next half hour was a modestly disgusting routine of suctioning his small nose of sticky secretions, adding saline drops, and suctioning again. Gradually, his breathing regularized with no squeaky sounds. I gave him some aminophylline to (hopefully) stimulate his respiratory center. By now however, he was again truly cold. The sun had still a half-hour before its debut and we were out of hot water.

Thinking things were at least stable, I went back to “house six” made up some breakfast and recharged the bottles with hot water from the geyser. Walking back, a box of bottles perched on a shoulder, with breakfast in hand, I considered that I had defeated the powers of disease and chaos rather handily. I swung into Paeds with my burden as rounds were starting. His bed was empty, the family gone and a few cold IV bottles surrounded the emptiness. An empty space.

I rechecked on my baby in the incubator. His temperature was normal, all signs of respiratory distress was gone, he was pink and well perfused but not feeding as well as previously. Considering he was most of the way to “well-done” a few hours previously, I was content.

In mid-afternoon a maternity worker brought me a chart. Scribbled at the bottom of the nurses’ notes: “baby stopped breathing. Chaplain called. 1403.” Another empty space. So far all small or sick babies who have been admitted have died.