Malnutrition is one of the major health problems for the children of the developing world. More than half of the world's children live in poverty, and many of these children suffer from malnutrition.
Malnutrition is a complicated problem with socioeconomic, medical, nutritional, and psychosocial determinants. This article reviews some of the psychosocial aspects of malnutrition and provides an example of an intervention program for malnourished children at Hôpital Albert Schweitzer in Deschapelles, Haiti.
Like children with many other serious or chronic illnesses, children who suffer from the severe forms of malnutrition - kwashiorkor, marasmus and marasmickwashiorkor - are at increased risk for psychosocial problems and require psychosocial support to optimize and speed rehabilitation. Conversely, psychological factors also can precipitate or exacerbate these forms of malnutrition, as is seen in the nonorganic failure to thrive syndrome of developed nations. Nonorganic failure to thrive is a recognized psychiatric disorder and is referred to as "feeding disorder of infancy or early childhood." Parental psychopathology and parentchild interaction problems can be associated with or contribute to this problem.1
Absent or faulty maternal care also has been understood to contribute to the development of severe malnutrition in children of the developing world. Dr. Cicely Williams, working in 1933 in what is now Ghana, was the first physician to introduce the term kwashiorkor in the medical literature and to explain its origin. Kwashiorkor comes from the Ga language and means the illness suffered by a child who has been displaced from the breast by a younger sibling.2 Subsequently, other investigators have studied the relationship between parent and malnourished child and described links to maternal mental illness, psychosocial stress, and separation of the child from his mother.3-6
Standard guidelines for the treatment of malnourished children now include attention to psychosocial concerns. The World Health Organization monograph on the treatment of malnutrition gives several suggestions for stimulation of the malnourished child such as pleasant surroundings, exercise activities, play, and music.7
At Hôpital Albert Schweitzer, which has decades of experience in caring for malnourished children, the value of psychosocial support for children and correction of disturbances in parent-child interaction has also been recognized. A psychosocial intervention program was therefore implemented to promote positive parent-child interaction.
Hôpital Albert Schweitzer is located 90 miles northeast of Port-au-Prince in the Artibonite Valley and serves 300,000 residents within a 610-square-mile district. Dr. Larimer Mellon and his wife, Gwen, founded the 190-bed hospital in 1954. Five decades later, severe malnutrition continues to be a serious problem for the children of the valley, especially during the months of July and August, just before the harvest season. Malnutrition is the most common diagnosis for all children seen in the outpatient department as well as those admitted to the hospital. While many less severe cases are treated as outpatients and in community programs, children with marasmus, kwashiorkor, and failure to thrive with continual weight loss are admitted to the hospital for medical stabilization and nutritional and emotional rehabilitation.
The hospital is divided into departments of medicine, surgery, and pediatrics. Along with a 60-bed pediatric ward, a separate ward known as Ward III is designed for the malnourished children who have been stabilized and are now undergoing nutritional rehabilitation. There are places for 24 children in Ward III. A caretaker, usually the mother but possibly the father, grandparent, friend, or even a young sibling, stays with the child and provides daily care. The vast majority of such hospitalized children are younger than 4. Nursing staff delivers food, milk, and medications to caretakers, who in rum are responsible for giving them to the child.
The hospital has a protocol for the diagnosis and treatment of the malnourished child. This protocol includes routine lab tests such as complete blood count, urinalysis, chest x-ray, tuberculin skin test, and usually HIV testing. Children are examined and treated for sepsis, hypoglycemia, and hypothermia. After stabilization, they are treated for parasitic diseases, vitamin deficiencies, and irondeficiency anemia. Each child receives a carefully calculated amount of fortified milk 5 times a day, as well as food.8 Caretakers also are provided with meals. Nursing staff gives instruction on proper nutrition for the child.
WARD III BEFORE PSYCHOSOCIAL INTERVENTION
Before the initiation of the psychosocial intervention program. Ward IH was a somber place, with little talking or children's banter. It was a place for sitting, sleeping, and eating. Apathy was evident in the faces of the parents and the children.
Observations of the parents and children on Ward III showed that, in contrast to many other settings where all family members are malnourished, the parents of these children frequently appeared healthy and well fed. It seemed that more than a shortage of food was causing malnutrition in these children. Further observations suggested a derailment of the relationship between the parents and the malnourished child. There was little eye contact or physical contact between the malnourished children and their parents.
The children and their parents did not play together; there was no evidence of joyful interaction. The children would sit on the floor motionless, surrounded by a few toys. The mothers often appeared sad and distracted. The infants would cry, and no one would come to their aid. When food arrived, mothers would frequently feed themselves. Young children, 10 months to 2 years old, were placed on the floor with a plate of food in front of them and expected to feed themselves. Sometimes young girls were left to care for their younger siblings. Children caring for children is a frequent occurrence in Haiti.
Several mothers of infants younger than 2 were pregnant. On one occasion, of the 15 hospitalized malnourished children, seven of their mothers were pregnant. Some mothers had a healthy, breastfeeding infant and a sickly, malnourished 2- or 3-year-old child, often miserable, with a feeding tube in place. The mother would interact with her breastfeeding infant, while the older child would sit alone with a sad expression on his or her face.
Many mothers appeared withdrawn from their children. At the same time, some of the children were quite difficult to care for and did not allow interaction. This was especially apparent during feeding. Some of the children would turn their heads, refusing the food or milk or spitting out what was put in their mouths. One child who was crying cried even louder when her mother tried to comfort her. Other children did not respond to their mothers' attempts to play with them. All the children had fine motor, gross motor, and speech delays, along with disturbances of interaction.
Social histories revealed many factors that could interfere with a joyful, growth-promoting parent-child relationship. Many mothers worked in the market. Unlike women in many parts of the developing world, Haitian mothers do not tend to take their infants with them when they work in the fields or the market. Infants often are weaned abruptly so their mothers can return to work.9 These infants are then left in the care of their young siblings. Several women had been deserted by their husbands. A study showed that 40% of women in Bastien, a community close to the hospital, were abandoned by their husbands.10 Other women were sick or depressed. Many had experienced the death of a husband, a parent or a child.
Some children hospitalized on Ward III had been abandoned by their mothers, or their mothers had died. These children often were cared for by resentful relatives. Each family on Ward ?? had something in their social history that could cause emotional and/or physical disruption in the attachment between the mother and the now malnourished child.
THE PSYCHOSOCIAL INTERVENTION PROGRAM
The Psychosocial Intervention Program at the hospital evolved through many phases during a period of several years. The first step was to educate the staff, both Haitian and expatriate, about the importance of psychosocial interventions in the treatment of the malnourished child. Not surprisingly, proper food and J medicine alone were thought to be treatment enough.
Initially, funding for the intervention program was insufficient, and implementation was sporadic, relying on volunteers who were present for varying periods of time. Funds eventually were donated to hire a Haitian nurse supervisor. There was then a period of trial and error to find the interventions appropriate for the Haitian parents and their children. For example, the World Health Organization recommends that mothers sew a toy for their children, and the monograph offers directions on how to make a doll. This activity was a failure because the Haitian children were not interested in playing with the doll. They preferred a toy that they could throw, so the mothers made cloth balls instead.
Supervision and instruction at mealtimes is another important aspect of the program. There is now an organized program in place, with a daily schedule supervised by a Haitian nurse and nurse auxiliary. Children and their parents are no longer left to eat on their own, apart from each other with no interaction. Instead, eating is now a group activity on an adjacent porch. Staff members supervise mealtimes, teach feeding techniques, help with children who are difficult to feed, and teach parents to make feeding a playful, social interaction. Even during evenings and weekends, Haitian auxiliaries are present for instruction and support of the parents as they care for their malnourished children.
The ward was refurbished with curtains, a fresh coat of paint, and new mattresses and sheets for all the cots. In addition, a new cooking area has been constructed adjacent to the ward. Now parents are supervised in shopping for appropriate foods in the nearby market and in the preparation of nutritious meals for their children and themselves.
It was observed that the mothers and the children became lively and interactive with the introduction of music, dancing, and singing. They enjoyed play that was active and involved doing something, such as throwing a ball or putting together a puzzle. They were less interested in imaginative play. Based on these observations, Haitian music is now played periodically throughout the day. There is a morning exercise session to music for the mothers, and many of the children who are feeling better join in as well. Each afternoon, there is a supervised play session with toys, followed by time for mothers to massage their children. The mothers have made up a song that they sing as they do the massage. This song has now become part of the life of Ward III. One day a week the mothers are instructed in sewing a toy for their children. The day often ends with the parents singing and dancing with their children.
The mood on the unit is greatly improved. Throughout the day, there is talking as well as the chatter of children playing. Sometimes the children tease each other or fight over a toy; this is certainly an improvement over children and parents listlessly sitting on their beds. Especially during activities such as exercise and play, there are now smiles on the faces of many parents and children. A Haitian staff member familiar with many facets of malnutrition functions as a social worker, helping families with their problems and with the transition back into the community at the time of discharge.
The psychosocial intervention program for malnourished children at Hôpital Albert Schweitzer has evolved over several years and now consists of daily interventions including music on the unit, cooking and feeding instruction, exercise sessions, supervised play sessions, daily massage of children by their parents, toy making, and singing and dancing. The interventions are supervised by Haitian personnel and have been developed according to what is interesting and stimulating for Haitian parents and their children.
These interventions appear to have greatly improved the moods of the parents and their children. They seem happier. There is more interaction between the parents and the children throughout the day, including touching, playing, and talking. The feeding situation has improved. Parents feed their children; there is more socializing and eye contact during meals.
Our experience supports the concept that the rehabilitation of the malnourished child is facilitated by interventions that restore a positive parent-child relationship. These interventions should be tailored to the local culture. Future studies could evaluate the effect of such interventions on the parent-child interaction at the beginning and end of the hospitalization, as well as on parameters such as mortality, rate of weight gain, length of stay, and readmission rates.
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