Shihaam Cader is the Chief Dietitian and Head of Dietetics at Red Cross War Memorial Children's Hospital in Cape Town. After more than 16 years at Red Cross, Cader and her team have helped to treat and rehabilitate thousands of malnourished children that have come through the hospital's doors. Sitting down with Spotlight, she highlights just how complex treating malnutrition in children is, and warns that the COVID-19 pandemic and lockdown period may impact childhood malnutrition in the country.
Red Cross is a specialist tertiary hospital, meaning that the facility sees the worst medical conditions that cannot be resolved at a clinic or at a district hospital level. Cader explains that the hospital works mostly with children with chronic conditions such as kidney or liver disease, and malnutrition may be a result of these conditions or from hunger experienced at home.
"Severe acute malnutrition may be as a result of lack of access to adequate food, or some [children] might have access to food but are not meeting their nutritional requirements [due to a possible medical chronic condition that requires higher calorie needs," she says.
The typical malnourished child, she adds, has no access to food at home or the foods they have access to lack protein, fruits, vegetables and are mostly starch-based. Foods high in starch, like maize meal and potatoes, are common staples in poor households but contain little to no nutritional value on their own.
"There're different ways to think of how malnutrition fits in the picture," says Cader. "Is it just purely because there is no access to food, or are they getting food but they're not gaining the weight because they have higher calorie needs and there's another medical cause for the malnutrition."
"Not forgetting the other form of malnutrition which is obesity, which is another discussion on its own," she adds.
Malnutrition related hospitalisations can fall into two potential clinical categories, severe acute malnutrition (SAM) or moderate acute malnutrition (MAM). See the WHO's definitions of SAM and MAM here.
Western Cape numbers stable
According to the Western Cape health department, between the months of April and September of this year, 152 children were hospitalised with SAM and 101 with MAM. This data does not show an increase when compared to the same time period in previous years, says Assistant Director of Communications at the department, Byron La Hoe. However, it is unknown how many children in the province with SAM and MAM were not diagnosed and linked to care during this time frame.
"When we do get [children with] severe acute malnutrition, particularly as a result of lack of access to food, [the numbers haven't] really changed [during the lockdown period] but my suspicion is that it might be related to different levels of hospital care," says Cader. "We get the specialised, severely complicated types of patient so what happens is that [children] that don't have these complicated medical conditions would go to a lower-level [facility] such as district hospital."
A slow process
Treating malnutrition is a very slow process, explains Cader, and requires constant monitoring and slow feeding in the beginning before a "catch-up phase" is reached, and then finally the long-term care rehabilitation phase. Red Cross follows the WHO's 10 steps for management of SAM protocol.
"It depends on age, but most [malnourished children] would end up having to be tube fed because they're so miserable and so unhappy." Based on the age of the child and needs of each patient, they're tube fed with the appropriate nutritional product at a very slow rate to avoid what is called re-feeding syndrome. Re-feeding syndrome is a process where, after a period of starvation, the body experiences electrolyte shifts when glucose is given as a source of energy, explains Cader. "Logically one would think we should [flood] them with calories but actually we do things very slowly in the beginning to prevent these kinds of complications."
"We would then rely on other multidisciplinary team members such as occupational therapists for their developmental input and the social workers to ensure that the home we eventually send the child back to still supports the ongoing rehabilitation of the child and that we don't send them back to the same environment that they came from," says Cader.
In the beginning a lot of the focus is on getting the child medically stable, but this final phase of rehabilitation and long-term care is critical to prevent the child from relapsing and coming back into the system, which Cader points out used to happen in the past before this multidisciplinary team approach was put into place.
In addition to team members from Red Cross, the child would also be referred to one of 40 community dieticians in the province to ensure their care continued at home.
"I think the benefit that we have as a province [is that] we've got a nutritional programme that allows us to refer patients where they can access additional forms of nutritional supplements," says Cader. But, she states that the programme doesn't solve issues around food insecurities, rather it merely aids to provide additional protein and calories for children with chronic conditions or those with acute malnutrition.
This supplementation programme is part of the province's Integrated Nutrition Programme and currently has 1 345 children under the age of five enrolled. La Hoe says that according to the province's data, the number of children enrolled in this programme did not increase during the months of April and September, compared to the past three years.
Breastfeeding and the first 1 000 days
Speaking from experience, Cader says that children between the ages of six to nine months, up to one year, are most at-risk of malnutrition related health issues. At around six months, babies transition from breastfeeding to solid food, but often parents and caregivers have difficulty feeding nutritious, whole foods that support the baby's growth and development.
"From the South African Demographic Health Survey of 2016, there was an indication with introductions of solids the types of foods [and] the choice of foods that was given to those age groups 6 to 23 months was inadequate, so there is need to focus on how do we teach or educate our community about choosing the right foods," says Cader.
In line with the Integrated Nutrition Programme, a primary focus of the provincial department is on breastfeeding and the first 1 000 days. "My team as a whole focuses on the first 1 000 days. We focus a lot on our infants who are newly breastfed, [and] a lot of education and focus is done on moms to understand what it means [to breastfeed] and debunk the myths."
Some mothers or caregivers may think that if they are hungry or malnourished their breast milk will not be suitable for feeding, when this is not true. Cader adds that another myth is that breast milk that appears discoloured, or "too thin" or watery is not adequate for infants - while in fact it is.
"Other [reasons why] moms tend to stop breastfeeding is that they believe that they don't have adequate breast milk supply, so there's a lot of effort put in place to ensure that they get fully educated, and supported to ensure sustainability and that mothers continue breastfeeding," says Cader.
Addressing stunting and micronutrient deficiencies
Without exclusive breastfeeding for the first six months and adequate nutrition, children risk becoming stunted (too short for their age), which could have severe consequences for their cognitive development. Up to the age of two, the effects of stunting can be reversed with proper nutritional supplementation, says Cader, though some effects can be corrected up until the age of five.
South Africa's current stunting rate is about 27 percent, or more than one in four children, a statistic that has increased over recent years. "What makes that worse is that our overweight numbers have also gone up," adds Cader. "Our wasting [low weight for height] has come down, but our stunting has gone up and we foresee obesity increasing as well."
From 9 to 19 October, the National Department of Health celebrated Nutrition and Obesity Week, which focussed on good nutrition for good immunity during the COVID-19 pandemic. Cader says that families are accessing mostly processed food sources during the lockdown period due to the low-cost and the longevity, or shelf-life of the foods.
"Fresh fruits, vegetables and your better quality foods are usually more expensive [and] unaffordable to many households. These factors ultimately all contribute to risks of worsening the obesity rate in our country. So one of the focus areas of nutrition week this year was to remind the public that you can still access affordable foods that are of good quality."
Cader says that fruits and vegetables are not thought of first, and that many families often spend money on more starch-rich foods like maize meal, which can lead to a lack of vitamins and minerals in the diet, or what is called micronutrient deficiencies.
"We see that in South Africa. We've got Vitamin A, Zinc and Iron deficiency [and] that is lack of adequate nutrition. So bellies are full but they lack the hidden forms of nutrients that are required," says Cader. Micronutrient deficiency is also known as hidden hunger.
By addressing micronutrient deficiencies, Cader says that stunting could be reduced. "Monitoring all micronutrient deficiencies is very hard, but I think we're at least recognising that micronutrients deficiencies plays a role in addressing malnutrition." Obesity and underweight (or stunting) are known as the double burden, and depend strongly on access to quality, nutrient-rich foods, and exclusive breastfeeding during the first six months of life.
Western Cape to prioritise child and maternal nutrition
La Hoe assures Spotlight that the department is monitoring child malnutrition and hunger in the province closely, and is working with other government departments to address the risks.
"Increased coordination efforts are in place to manage humanitarian efforts for families that are food insecure and increasingly vulnerable." Adding to this, La Hoe says the province has put in place a Maternal Child Health response plan inclusive of nutrition guidance in response to the COVID-19 pandemic.
The plan reiterates Cader and La Hoe, with a strong emphasis on safe infant feeding, nutrition support and counselling for families and caregivers, and calls for strong collaboration between the department of health and social development to address food insecurity and malnutrition in households.
The plan prioritises this collaboration between departments; "In an environment where child malnutrition is rife, and household food security is under serious threat, provision of, and access to food; and ensuring adequate nutrition of children is paramount," it states.
"The province will continue to prioritise nutrition as part of the comprehensive service package for Maternal and Child Health services as part of the life course," says La Hoe.
*When kids go hungry is a six-part series looking at the impact of the COVID-19 pandemic and lockdown on the nutritional status of children in South Africa. This series is supported by Media Monitoring Africa as part of the 2020 Isu Elihle Awards.