Malnourished children are vulnerable and so hospital stay should be minimised where possible to prevent infection. In the UK, children with failure to thrive are managed as much as possible in the community also, with close monitoring after the acute period of illness.

Mothers where I have worked have often expressed the need to leave due to conflicting priorities such as other children or the harvest. In South Sudan we trained and employed local women who had previously been traditional birth attendants to provide feeding support to mothers who were struggling to feed their babies.

SAM at this young age is possibly a co-morbidity but are more often results from the common breastfeeding problems which could be perceptions of inadequate breastmilk, mixed feeding, low breastmilk demand by the infant, lack of attachment and positioning knowledge, among others. Identifying the source of the problem is often paramount in managing the SAM. It could also indicate the need for a community approach in health promotion, in this case exclusive breastfeeding.
I agree with Dr. Garry on where to management the identified cases. The SAM cases just need stabilisation if very advanced or with complications, and then everything else is best done at the community level. This not only ensures care for the “other children” but also puts the mother at ease and gives her more confidence on her ability to manage her child, this is in addition to the social support by other family and community members.
All the same, I look forward to the findings of the investigation.

Dr.Gitau wrote about SAM in <6 month old babies and list the major factors behind it.
I am experiencing here in Panshir-Afghanistan how serious the situation of breastfeeding is.
There is a Real epidemic of mothers who 'feel' and declare that their milk is ' not enough'.
Doctors and nurses seem to be not aware about the danger of powder milk: it is easily sold in pharmacies owned by the same doctors.
I wonder whether health authorities in Kabul feel concerned about this 'epidemic'.
For God sake 'my' mothers in Tanzania cannot afford to buy Any milk: therefore breastfeeding is widespread and SAM very low and never (!) in under six months.
I scream....I ring the bell...please help me. Mothers in Afghanistan are victims of market...they deserve respect.
Massimo Serventi
Pediatrician
Panshir
massimoser20@gmail.com

Hello Massimo, I am a nutrition officer and not a doctor.

Thank you for highlighting the issue of infant formula in Afghanistan. It is really disheartening that the people mandated with promotion and protection of optimal breastfeeding are the same people wrecking it. I now understand why The UN states that “about half of Afghan children are not breastfed”.

The issue of health workers selling the formula seems to me like a classic conflict of interest case, although the code on breastmilk substitutes doesn't explicitly prohibit them from doing it. They may be taking advantage to make quick money. Its probably a lacuna in the The International Code of Marketing of Breastmilk Substitutes. However feel that the following phrase should be enough to deter them;

Health workers should encourage and protect breastfeeding ...

In crisis and emergencies, NGOs working in the area, the country ministry of health and other players in the humanitarian work are mandated with monitoring such issues, am not sure of the situation and players now. Contacting the UNICEF country office might give insight on the issue and offer possible relief , assist in contacting the relevant area officials and ensure a more protected infancy to those little ones.

In supporting the mothers, qualified breastfeeding support, assuarance on the mothers' ability to adequately breastfeed, social support and community-targeted health promotion on the issue might help. Cultural issues around the female anatomy and the mothers' nutrition status may also hinder breastfeeding and contribute to sentiments of 'inadequate breastmilk', here, the nutrition team in the area may be of support.

Note: If pre-crisis use of infant formula was prevalent, then artificial feeding would likely crop up. Previously, there were reported incidences of donations of infant formula which could also be a factor in the current problem.

( If you happen to follow up on the health worker issue, please lets know of the outcome )

Dear Massimo
Sorry to hear about this situation and your frustration. Here in Cambodia, there is also an "epidemic" of "not enough milk".
Talking about breastfeeding antenatally is so important. We have had some success with assuring women that their bodies made a baby (that's the hard part) so of course their bodies will feed a baby (that's easy!). We separate lactation and breastfeeding, telling women that their bodies will make milk - they can't stop it - but that breastfeeding is a learned skill that will need time and support.
We also find that the first few days after birth in the clinic are a danger time. Health professionals and mothers are insufficiently informed about colostrum and need to be reassured that it is there in small powerful doses, that it's personalised medicine for their baby.
So much is about building women's trust in themselves and their bodies (easier said than done).
Each setting is different, and just as the formula pushers do their market research to ensure that they are hitting mothers' weak spot, we need to do the same. We need to be talking to mothers about breastfeeding in language, images and issues that speak to them and their situation.
Good luck Massimo! You aren't alone in your frustration - let's use it as fuel to keep promoting breastfeeding and protecting children's and mother's health and wellbeing!

From Fatema Mofid-Ayat:

Dear Dr. Serventi,

Many many thanks from this kind of your feeling about Afghan women and children. Artificial milk companies is a real issue in many provinces of Afghanistan. Would it be possible to fill the attached Code Violation Monitoring Checklist? I'll circulate it with ministry of public health for more follow up.

Best regards

Fatema Mofid-Ayat

I will forward the form to Dr. Serventi

Mothers perception on not having enough breast milk is every where and becoming some what common in urban areas of Ethiopia. It needs research on why mothers are refraining from breast feeding , unless appropriate intervention mechanism applied it may worsen the situation of SAM in under 6 mo.

I see there are a lot of similar viewpoints from around the world! It's common here in the UK, and pretty much everywhere I have worked. And very challenging to tackle.

There was a focus on this in the Lancet earlier this year: http://www.thelancet.com/series/breastfeeding

Especially interesting out of those articles is this one, which looks at the influence of formula on clinical practice: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00103-3.pdf
This is currently being hotly debated in the UK.

Mothers and healthcare workers are often so far apart in terms of understanding and knowledge levels, and in how they communicate. Regarding the breast feeding support workers we trained and employed - this was a time consuming but potentially worthwhile use of resources. I have done this in Haiti and South Sudan, and worked with them in a multitude of settings, and seen excellent results.

Mothers tended to listen to other mothers and older women in the community. We trained women specifically to spend time with mothers on the postnatal wards, in the baby unit, and in the kangaroo mother unit, to provide hands on advice, support, and create peer- groups to discuss breastfeeding. The 1st step was educating them regarding the benefits of colostrum, breastmilk, patience, expressing and storing breastmilk, etc etc. We used pictures, and a lot of time and patience required!