Combating malnutrition

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Wednesday, July 30, 2014

"IT TAKES a village to raise a child," according to a popular African Proverb. Hence, every help is needed to save a child's life from severe acute malnutrition (SAM) that just claimed another life in Davao City in July, 2014.

The five-year-old girl, whose death was only found out by the Action Against Hunger (ACF) International-Davao on July 22, was the fourth death recorded under the Outpatient Therapeutic Program (OTP) of the Integrated Management of Acute Malnutrition (Imam) in Davao City.

The said girl from Davao City's District C (Sta.Ana), who has a twin and three other siblings, was enrolled with the OTP. While undergoing treatment at a hospital, however, she was brought out of the hospital by her family against medical advice and was later found out that she had died.


ACF International-Davao head of program of nutrition Dr. Celna Mae L. Tejare, in an interview, said, "The death of the child is still being investigated. Nilabas kasi against medical advice. Hindi ganun ka compliant sa treatment. Late narin pagdala sa hospital."

The state

Dr. Tejare said a child with SAM is 9.7 times more likely to die compared to a healthy child.

Of the four SAM deaths in the city since the OTP began in April 2014, three were from Poblacion-District C (Brgys. 21-30) and the other one was from Bunawan District. Some District C SAM cases were victims of the April 4 fire that razed slum communities in two barangays at Isla Verde.

Based on Imam monitoring and evaluation, the city currently has a total of 312 SAM cases as of July 28 from 173,356 screened. The 297 were classical cases, including the four deaths, while 15 are special cases or those with complications. Congenital-related diseases and cerebral palsy are among these complications.

While regular SAM cases takes 58 days to two months for treatment, special cases take about three to four months. Beyond that, a special case becomes a non-responder. A probe, however, will have yet to be done before a SAM case is declared a non-responder.

The Poblacion District has the highest number of SAM cases with a total of 64. Of which, District C has 35 cases; District A (Brgys 1-10) with 18; District B (Brgys. 11-20) wtih seven; and District 2 (Brgys. 31-40) with four.

Marilog is second, registering 60 SAM cases, while Bunawan District (42) is third.

Talomo ranks fourth with 24 cases (15 in Talomo South, five in Talomo North-1 and four in Talomo North 2); Agdao and Tugbok Districts share the fifth spot with 22 cases each; Calinan District (16) sixth; Toril District (15) seventh; Buhangin District (14) eighth; Paquibato District (13) ninth; Sasa District (10) 10th; and Baguio District (8) 11th.
Meanwhile, of the 312 SAM cases, Dr. Tejare said 80 had been cured. Cured in Marilog were 18 kids, Bunawan (16), Poblacion (14), Tugbok (8), Calinan (7), Buhangin (4), Sasa (4), Talomo (3), Toril (3), Baguio (2) and Paquibato (1).

Among those cured was Jojo, a Badjao, who was six months when enrolled with OTP although there was no birth certificate presented to ACF. In an ACF-Davao photo before his treatment, Jojo was "skin and bones" but he's now a picture of a healthy baby after three months of treatment.

ACFP International Philippine Mission advocacy coordinator Deewai Rodriguez also cited Josh Bustamante whose mother had no idea that her son has SAM. His mother, however, noticed that he was thinner than the rest of his siblings and that he doesn't play as they do.

"Josh rarely smiled," Rodriguez said. It would have been fatal if Josh did not start the treatment.

"My son smiles again," Joshua's mother said as quoted by Rodriguez.


Children born in early marriages and teen pregnancies, according to Dr. Tejare, are most likely to develop SAM as their mothers are not yet ready to care for them.

"Mother's care practices play a key role in a child's health and nutrition. It starts early on during pregnancy. The first 1,000 days of the child is very crucial. A baby should start breastfeeding since birth and complementary feeding of semi-solids like porridge with mashed vegetables starting six months," Dr. Tejare said.

She added that if mothers don't have a good and healthy pregnancy, their child will have a possibility of becoming malnourished.

SAM cases are prevalent in children from zero to five years old.

Dr. Tejaro also cited poverty as a major factor in malnutrition.

"May case kami na hindi maipagpatuloy ang treatment kasi hindi nakakabalik sa amin. There's a case that the parent and the child need P500 for fares just to get their ration. Dahil walang pamasahe, hindi natuloy nakakapag-treatment," she added.

Barangay nutrition scholars (BNSs), who do the screening and monitoring in barangays, could not also afford to reach those in remote areas as they only receive P1,000 honorarium per month without any transportation allowance.

Dr. Tejare said, "We can't really push the BNSs since they don't get any salary for doing what they do. If they spend for their fares in going to far-flung areas, what would be left of their P1,000 monthly allowance?"
The health-seeking behavior and practices of parents, she said, will also reflect on the health of their children.

Detecting SAM

Rodriguez underscored the "pockets of severe malnutrition in the entire city" despite having a health center, a health officer and a midwife in each of the 12 the 12 districts. Each district also has barangay health workers (BHWSs) and BNSs.

She said accurate identification of SAM children requires the proper use of anthropometric tools such as the Mid-Upper Arm Circumference (MUAC) tape, Salter scale and Height boards.

"Identification of acutely malnourished children does not only require the provision of anthropometric tools. It is also imperative that health and nutrition workers undergo a thorough orientation on the proper use of these measurement tools and an appreciation on the need and the urgency to identify acutely malnourished children," Rodriguez said.

She said anthropometric tools are provided by the Department of Health and Unicef in Davao City while ACF provided the technical assistance in capacitating health and nutrition stakeholders in the Davao City local health system on the proper use of the tools and a thorough understanding on SAM as a disease.

"The ideal scenario is that caregivers would make it a habit to have their children regularly screened in the health facilities and not wait for the periodic Operation Timbang and Growth Monitoring and Promotion schedules," she said.

Rodriguez thus cited BNS Evelyn Pinggoy, who has been serving Josh Bustamante's community for the past 12 years, walks on foot when she does not have extra money for her transportation to conduct Josh's weekly weight monitoring. Josh resides in an uphill area.

"Evelyn said she ‘finds joy in being able to help her community'," Rodriguez shared.

Identifying acutely malnourished children, particularly those living in far-flung areas of Davao City, is indeed tougher if not for the sacrifice of the BNSs and BHWs.


Acute malnutrition is not only a community concern but also a concern of government leaders, Rodriguez said. Thus, ACF fulfilled a significant role in advocating it as Davao City Mayor Rodrigo Roa Duterte signed on May 27, 2014 the Executive Order (EO) No. 26 that integrates and operationalizes Integrated Management of Acute Malnutrition (Imam) in the city's health system.

Dr. Tejare said, "This protocol is new. The first to be implemented city-wide in the country. Others have started this only in certain barangays but in an entire city or municipality."

The Imam, according to Rodriguez, "embeds the sustainability and longevity of acute malnutrition as not only a community and public health concern but also a governance concern."

"In the long run, institutionalizing PIMAM in the government’s health care system along with the other malnutrition prevention mechanisms (e.g. MNCHN, PPAN, IYCF) will create a better Health and Nutrition response leading to community development," Rodriguez continued.

Mayor Duterte, she added, allocated P6.5 million to address moderate acute malnutrition.

"Our ultimate goal is zero malnourished child. Prevent and maintain at zero. We don't want to treat and treat every year. We will continue with our campaign in education and care practices," Dr. Tejare said.

Published in the Sun.Star Davao newspaper on July 31, 2014.


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