Kwashiorkor

There was a boy in bed 13*.  He was about one year old, with huge dark eyes, and such a smile.  I would have taken him home in an instant.  Him and his mother, whoever she was. 

He had the rusty orange hair of extreme malnutrition, and skin so pale from anaemia that it looked almost translucent.  Even by usual hospital standards, he should have been sitting up, but he didn't even have the strength to try and sit with help.  His arms and legs were like sticks, impossibly fragile, while his abdomen bulged so that he looked uncomfortable in any position but lying on his back.  The area of his swollen liver was visible, and when I changed him, I could barely fit the disposable nappy on between his shrunken little hips and swollen belly.  Think of a picture you might have seen of a starving African child in a famine, and then imagine that child with white skin and reddish hair.  This child was starving to death.  Yet he smiled.  His eyes would search out mine , and as soon as he'd made contact, his smile would spread all over his face, and his weak little body would wriggle with pleasure.  Someone loved this boy. His name was Nicolae.

 

I worried about him.  Had he made it to the hospital in time?  Would they be able to give him the care he needed? Surely someone who loved him would come back for him, and not leave him to be sent to an institution.  He had a way of twisting his head back and forth, jaw locked open, and his hands stayed fisted unless coaxed open; worrying signs in a place where something as minor as a feeding difficulty or mild learning disability might sentence a child to life in an institution.  Was there some condition underlying his physical state, or had the malnutrition already caused brain damage?

 

I double-checked the symptoms when I got home.  Severe anaemia, reddish hair colour, swollen liver, the bloated abdomen and muscle wasting on the limbs.  Kwashiorkor.  Advanced kwashiorkor.  It is a particular form of malnutrition, caused by lack of protein.  Not the first case I'd seen by a long shot, but definitely the worst.  I knew the common scenario: mother unable to breastfeed, family can't afford milk or safe bottle feeding, so the baby is fed on tea, usually with crumbled biscuit mixed in.  It keeps them alive, but there are few calories and no protein.  Babies of less desperately-poor families are likely to be given soups that will have had bones or meat boiled in them, but some live hand-to-mouth, knowing only that babies should have white bland stuff and tea, with no knowledge of nutrition and the importance of protein.  Even in doctors' offices I have seen brightly illustrated advertising posters aimed at wealthier parents, stating that children must only be fed baby food, milk and fruit until 3 years old; no meat, no 'grown-up' food.  It is no wonder that so many children among the general population suffer from stunting - and how much more difficult for families on the outskirts of society to know what is best for their children.

 

But for a child as malnourished as Nicolae, food could be deadly.  He would need very careful feeding to bring him slowly back to health without overtaxing his damaged organs.  I dug out my books on caring for severely malnourished children.  Someone had given them to me before we left for Romania, though I hadn't thought I would need them.

 

Back at the hospital, I tried to talk to the doctor.  This boy, the one in bed 13, he needs special care.  I had training in infant feeding, I have a book...  But she brushes past, down the hall.  I could do it, I could show the nurses, I would come every day...  She holds up her hand and gives me a look, still walking.  She doesn't have to say anything. I am overstepping the line.  I am only a volunteer.  I am supposed to keep my place.  A volunteer is a volunteer, allowed into the hospital in the trust that they will respect the rules and let staff do their jobs, no matter what training or expertise they may have in their own life.  She is at the end of the hall, talking to a group of people in white coats with clipboards.  The hospital is busy these days, people are stressed.  If I interrupt, I could be jeopardizing the welcome that volunteers have in the hospital, and then where would all the other babies be?  Too much is at stake. 

 

The couple in the small private room - are they his parents? It is only a guess, they could be anyone.  I could speak to them, but they are waiting for someone, I don't know their situation.  I would need a translator.  Their poverty and obvious lack of nutrition don't mean they are his parents; they could be anyone.  If they are waiting for the social worker, they will wait a long time, because she is busy.  I know, because I would have gone to her first of all to offer my books to the hospital.  I just wanted to help this baby boy, and I knew the nurses already had a lot to do.  Maybe he would be looking better in a few days.

 

But on my next shift he was gone.  There was another baby in bed 13.  I looked for Nicolae.  Had he been moved? ICU?  The answer hit me like the kick of a horse to my belly.  Sent home.  Discharged. The doctor said he wasn't sick, so he didn't need to be there.  I guessed that was why she had not been interested in talking about him.  He had already been discharged.  Maybe those had been his parents.  Whoever took him home hadn't got to talk to the social worker.   Nobody had offered them any suggestions of where they might go for help.  Nobody had talked to them about how to feed their child.  The frailest child I had ever seen, yet he was deemed not sick enough to take up a bed in a busy hospital. 

 

I was not going to be continuing to work in the hospital anyway, but I couldn't have kept going in after that.  Not for a long while, anyway.  That sweet boy, with his huge dark eyes and his all-over smile. 

 

I haven't much hope that little Nicolae ever made it through what would have been his second winter.  Severly malnourished children are prone to dying of hypothermia, and the Transylvanian winters are cruel to families living in makeshift shacks.  They can also go into heart failure if given too much fluid - a considerable risk where soup or herbal teas are likely to be the only staples the family has to give a starving child.  I can only hope he went quietly in his sleep, in the arms of someone who loved him and taught him to smile.



*For the sake of veracity: Bed numbers and names are not accurate.