Cases Studies from Sierra Leone
Pascalle Delchevalerie, MSF - Belgium
Overall: In this program, we get more and more infants but half of them are premature
or LBW babies from the maternity ward (e.g. eclampsia, malaria...)
One problem met with the premature is the weight gain: babies clinically well, keeping
well their t°, tolerating well the feedings: probably because expenditure > intake, so we
decided for children < 1.5 kg, to use systematically feeding tube (at least every second
meal or each time the baby is asleep at meal time), to limit the frequency of breast
suckling, to spare energy and to manually express breast-milk to give it through NG
tube or by spoon, until the child is stronger and gains weight.
The tea m was provided with IFE manual for the training of the staff.
Case 1: Sengova
This baby, 3 months old is the 12th child (hospitalised in TFC since 1 week (admission
on 24/03/07)). L: 53 cm, W: 3kg W/H < 80%.
The mother successfully breastfed all her children, but this one, who was healthy
during the first month of life, started to loose weight after one month, the milk
production seems to be low. The child got fever on & off + cough.
The delivery (in Health Centre) was complicated by retained placenta causing
important haemorrhage (transfusion needed).
The mother is 44 years old, she got her first child at 25y, good birth spacing (2 to 3
years intervals). Her nutritional status is OK.
8 children still alive (2 died from measles, a pair of twins died: 1 at birth, the second at
1 month, form sudden unexplained death: the mother found him dead without history
of sickness: “syndrom of infant sudden death?”)
The baby looks hungry, finish all the complements but don’t gain weight even after
increasing amounts given (nearly twice the theoretical amount). No diarrhoea nor
vomiting.
One peak of fever on the 29th (38.3°C), otherwise T° between 37.2 and 37.5.
Received the systematic tt of Amoxycilline from 24 to 29/03 (+ from 31th to 4/4
because of fever on & off).
Discharged on 4/4 as cured: W 3.3 kg = 85%, suck well, no fever, no cough, no
diarrhoea.
NB: unfortunately, I missed several times his meals, so I couldn’t get a good picture
when he was breastfeeding or cup feeding, but at least, we have an example of poor
attachment (see picture 2).
Case 2: Zachiu
Mother with sickle cell disease, premature delivery (30 weeks) in MSF hospital, birth
weight 1.3 kg (24/03).
At 5 days, 1.28 kg. Drinks well. Good clinical status. Breastfed before cup feeding.
10/04: Grandmother request discharge due to domestic problems.
11/04: W 1.27kg, baby weezing & coughing. Mental health team talked to mother &
grandmother.
16/04: W 1.5 kg: strict monitoring of feedings, child breastfeding and cup feeding well
but not gaining weight. Grandmother continue to stress her daughter to discharge =>
new mental health consultation.
23/04: W: 1.4 kg diarrhoea on & off, no fever, no cough, no weigh gain, dehydrated?
=> nasogastric tube for feeding + resomal.
24/04: T°: 34.8°C: hypothermia => survival blanket
suspiscion of sepsis => Ampicilline IV + gentamicine, 50% dextrose, F75 milk
+ breastmilk expressed.
25/04: child transferred to ICU (Intensive Care Unit).
26/04: back from ICU, continue medical treatment. Mental health councelling to be
done, still fed through NG tube.
27/04: W 1.2 kg. Grandmother removed NG tube. Loose stool x 2. NG tube replaced.
Maintain strict 2 hourly feeds. Keep child warm. TT: metronidazole + resomal.
01/05: W: 1.4kg. OK. No loose stools. Takes the milk well. IV line removed, oral tt by
amoxycilline. Stop resomal.
02/05: lung clear. TT: Ceftriaxone. Eating well. Increase feeding.
05/05: child sucking well.
06/05: W: 1.4kg
07/05: all is well.
09/05: Discharged against medical advice.
Case 3: Hawa & Nemetu
Mother 17y, with pre-eclampsia, delivered on 22/03, twins.
Hawa (1st twin (8 PM),girl), 1.4 kg. Small for date.
23/03: 4am: T° 37.8. Neonatal sepsis, purulent eye discharge, not yet sucking.
TT: IV ampi/genta, Tetracycline eye ointment, daily cord dressing. Supplemental
feeding protocol phase 1.
25/03: vomited twice.
26/03: W 1.3 kg, T° 37.5
27/03: T°: 37.4 am, 38.2 pm.
28/03: W 1.25 kg. T° 37 am, 37.8 pm. Continue medication for 2 days.
30/03: feeding well.
01//04: W: 1.3 kg. Feeding well. Then up to 10/04 everything OK, but low weight gain
10/04: W: 1.35kg
11/04: diarrhoea => resomal according to protocol.
13/04: W: 1.19 kg. feeding well, no diarrhoea but looking weak. => dextrose 50%,
nasogastric tube feeding. Extra warmth.
14/04: dehydration + gastro-enteritis. Iv rehydration (100 ml Ringer + 10 ml dextrose
50%, rhythm according to standard protocol). Surveillance of vital signs 1 hourly.
15/04: vomiting. Hypothermia 35.3°C. Sepsis => IV Ceftriaxone. Feeding through NG
tube.
18/04: W: 1.1 kg.
19/04: mother removed NG tube. Not bringing the child for weighing. Mental health
speaks to mother. Replaced NG tube.
Child died.
Nemetu: (2d twin), 1.22 kg. Small for date.
Unable to suck.
Neonatal sepsis, IV ampi/genta, Tetracycline eye ointment, daily cord dressing.
Supplemental feeding protocol phase 1.
24/03: vomiting, diarrhoea.
25-26/03: feeding OK.
27/03: fever, feeding OK.
28/03: add another 2 days of ampi/genta.
Continue fever until 2/4 but feed well.
03/04 and following days: Weight stagnant: 1.39, 1.41, 1.40, 1.34, 1.35 (10/04), 1.32,
1.31
from 10/04: crying, coughing
11/04: loose stools x 5 => resomal according to protocol schedule. Mother given
advises.
13/04: child gasping, transferred to ICU => died.
Case 4: Vandy
Young mother 18 y, with inverted nipples. 1st child, 2 months old, 2.1 kg, admitted
28/03: sick with fever for 4 days, cough for 3 days, skin rash for 7 days.
Child has been given native medication.
Lungs clear at auscultation. Paracheck test (-).
Medical tt: Zinc oxyde on scalp, Amoxycilline for 5 days.
Nut tt: F100 diluted as per protocol.
Weight: 2.84 => 2.7 => 2.84 => 3kg on 03/04
Discharged to SFC on 03/04 (for follow-up of Infant formula provision).
For future, if no other solution will receive infant formula with follow-up through the
SFC programme.