Again that voice..chill! Even thorough this low watt, lamictal affected brain of mine I thought well this is either a case of the nurses not getting it as he hasn't really shown distress, other than he hadn't gained a flee-flappin', racka-frackin' gram and was too weak to kick up a fuss, or his mom just was not able to participate in his care. Each thought the other was at fault and the kid just stayed at 60% weight for height, severely malnourished, all the while the HIV and Tb were wracking what was left. They are the true hyenas of the infectious world.
How to get more calories into this little irritated chum and factor the adults out of it? Aha, says I. "Please get me a neonatal NG tube, a liter bag of saline ( a smaller bag would have been better but alas), and an adult administration set." Notice I didn't say get me the damn set! Good for me huh? I was after all still hearing that voice? " Now make up some of his formula but make it 1.5 the concentration." I did the calculations for this and out came a liter of formula.
I drained the saline from the bag, cut off a corner from the top and inserted the top half of a 20cc syringe, a funnel. Love me some Miny Leatherman Tool! Than, after assuring myself that the NG was in the stomach, poured the formula into the bag and hooked up the administration set (that clear tubing that leads from the bag to the iv) to the NG. It took a little futsing but by now I was in innovative heaven. Interestingly the NG tube revealed nothing in the stomach just an hour after he was supposed to have been fed. I gave a look of "really....Really!" and each of the parties pointed to the other.
Actually things came together rather nicely and in went the formula at a calculated drip rate to equal 200cal/kg/day. And what happened? The calculus as far as I can tell is this:
one irritated, starved kid (+)
one guaranteed source of warm calories =
same kid fast asleep.
I pointed out how we no longer needed to worry about who was going to give the food. We just needed to check the drip rate as we didn't want to over fill this guys microscopic stomach and give him aspiration pneumonia. They all agreed this was a good idea. Off I went to see referrals in the out patient department.
After I finished I went back to check on him and you can guess the rest of the story. To everyone's credit the NG was in place but the formula was off as the nurses didn't to "give him diabetes". "You mean fatten him up, get him sweet, why not?" We had a lengthy discussion about this during which I congratulated them about thinking about this but that even if he did get diabetes ( he couldn't) it was still OK to proceed. They agreed and one took the lead. We'll see next month.
His ward mate was also malnourished and was ready to be discharged but was on his mothers back so much that he couldn't sit at 19 mos. I sat him in a corner of his crib and his head draped forward. Everyone naturally went to his aid but I said to just wait and see what happened. One minute later he had great head control and was reaching out for some Plumpy Nut! I tried to get his mother to allow him to be a touch more independent but she would have none of it. She is San and desperately wanted to go home to the bush and be with her family. Fair enough, he'll develop there fine what with all the tactile stimulation he'll get but it would have been a touch safer to do it under some supervision. She had done her part in that he had gained 3kg in the last month and she wanted out. She lived with 8 other members of her family way out there. Would have been fun to go with her an see it.
Today I was at another hospital and saw the same situation, same malnourished child with HIV and Tb except this kid had lost weight in the last week. In went the NG, up went the bag, in went the formula, down he went. Cool.
