Understanding and improving the management of Kwashiorkor: results of a study in the DRC and Mali
Kwashiorkor is an acute and severe form of malnutrition, mainly caused by inadequate protein intake. This disease, which particularly affects young children, manifests itself in the form of bilateral oedema of the lower limbs. Many questions remain about the clinical description of the children affected, the nature of the oedema and the socio-cultural factors influencing its management.
To fill these gaps, Epicentre carried out a quantitative study between October 2016 and November 2017 at two sites: in Rutshuru, in the Democratic Republic of the Congo (DRC), and in Koutiala, in Mali. It was then supplemented by a qualitative study of health workers to explore their perceptions, practices and lessons learned from their experience in caring for children with Kwashiorkor.
Key data on medical care
A total of 1,611 children aged between 6 and 59 months were included in the study, of whom 16% in the DRC and 49% in Mali had grade 3 oedema, the most severe form. Of these, 70% in DRC and 52% in Mali had been diagnosed as suffering from severe acute malnutrition using MUAC (brachial circumference) or Z-score criteria.
The results also showed that more than half the children admitted to hospital had received little or no protein-containing meals prior to admission. Proteinuria was detected in 45% of children in Rutshuru and 8% in Koutiala.
7% of the children included in the study died during hospitalisation. The analyses revealed significant differences between the sites:
- In Mali, mortality was associated with grade 3 oedema, proteinuria and signs of acute malnutrition.
- In the DRC, only proteinuria was correlated with high mortality.
"This finding led us to recommend the systematic detection of proteinuria on admission in all children with oedema," recalls Jihane Ben-Farhat, head of the study and epidemiologist at Epicentre. But beyond the results, we found that health workers expressed divergent opinions on the causes and treatment of bilateral oedema, including those linked to Kwashiorkor. This observation led us to carry out a qualitative study, the first of its kind in these sites, to examine the perceptions and practices of health workers in relation to nutritional oedema, taking into account the socio-cultural context."
Perceptions of healthcare workers
In both sites, health workers mostly associated bilateral oedema with malnutrition or "nutritional oedema". However, establishing a differential diagnosis remained a major challenge.
As one participant put it: " In an ideal world, Kwashiorkor is diagnosed when you have ruled out other possible causes of oedema. But in our context, it's first, very difficult, second, people are just so used to say ‘there is malnutrition, there is oedema, it’s Kwashiorkor’”.
As a result, children are often treated immediately for nutritional oedema, unless there are clear signs of another pathology.
Barriers to access to healthcare
According to health workers, there are several obstacles to early treatment:
- Accessibility: the cost of transport and health centres, combined with the difficulties of accessing health centres in the DRC, are factors that can explain why children arrive late.
- Mistrust: A lack of trust in healthcare structures sometimes leads families to prefer traditional treatments.
- Socio-cultural factors: Decisions concerning the child's health are often taken by the patriarch, while the mother, who is responsible for accompanying the child to hospital, may lack support.
Recommendations for improving care
Health workers have identified several priority areas for stepping up the fight against Kwashiorkor:
- Strengthening prevention: Raising awareness among families, particularly mothers, of the causes and signs of the disease.
- Standardisation of diagnoses: Development of clear protocols to distinguish Kwashiorkor from other pathologies.
- Enhanced collaboration: Better coordination within the medical teams and more dialogue with local communities and traditional practitioners.
- Human resources: Recruitment of additional medical staff specialising in the management of acute malnutrition.
- Investment in research: Improving knowledge of risk factors and therapeutic approaches.
One health worker particularly stressed the importance of involving mothers in the care process:
"The medical team is too focused on care and often forgets the mother. For me, we should put more emphasis on raising the mother's awareness, explaining to her what illness her child has, and also explaining to her how this type of pathology can be avoided.”
A global approach to tailored care
This study highlights not only the clinical aspects of Kwashiorkor, but also the socio-cultural and organisational influences on its management," concludes Giulia Scarpa, a mixed methods researcher at Epicentre and the University of Leeds. Improving prevention, diagnosis and access to care requires a global approach, involving families, communities and health workers".
By strengthening these aspects, it is possible to reduce Kwashiorkor-related mortality rates and ensure better care for the most vulnerable children.
Crédit photo Laora Vigourt/MSF