This is a World Health Organisation growth chart for a child from birth to six months old. The Y axis follows weight in kilograms, while the X axis follows the age in weeks to 12 weeks, then in months to six months. The coloured curves traveling from the left to the right of the chart are percentiles. They predict, based on worldwide population studies, how a baby’s growth should travel based on their weight at birth. Baby Mary, who belongs to this particular growth chart, was born just above the middle green line, called the 50th percentile (which basically means that about half of all babies will be on or above this line, and half of all babies will be on or below this line). As you can see from the weights we have recorded, her actual weight is severely faltering. She has crossed all of the percentiles and her weight is “flatlined” well below what any baby of almost five months old should weigh.
We don’t know why.
The things we do know are:
She lives in a landless community who assemble tiny huts on the riverbank in the dry season, and in the wet season they disassemble their huts and live on their boats. Her parents are fishers, relying on a daily catch for daily income. There are only specific times of the year when fish supplies are reliable enough to guarantee catching enough for the family as well as some to sell for cash at market. Hunger is a common experience as is ill health and premature death. Her four year old sister has a neurological disability that looks like Polio, but is apparently a permanent sequelae from Tuberculous Meningitis as a toddler.
The second thing we know is that she was born in a maternity clinic who supplied her mother with a free can of artificial milk powder, a small baby bottle with the capacity for only 40ml of liquid, one teat and no education on how to feed the baby. Mary was 19 days old when I first met her and bottle feeding from an artificial teat was well established. Sadly I didn’t have the skills or resources to teach or encourage her mother about re-lactation, which might likely have been the best option. The second best option would have been trying to access donor human milk but I am unsure if that would be possible in this environment. Artificial milk is an inferior alternative for many reasons and particularly in such impoverished settings. It also feeds a highly lucrative corporate market, as I have discussed before.
When I asked her mother how she afforded to buy the milk powder she replied “when we can afford it, we buy it. If we cannot afford it we have to go without”. Feeding babies “rice milk” (the white liquid leftover from boiled rice) is not an uncommon practice and I have seen malnourished babies who were living on this. When I told an Australian friend Mary’s story she transferred enough money for six months of milk powder to my account the next day. Although solids should be commenced around six months of age, babies rely on milk until 12 months of age for their nutrition, and should not commence cows milk until 12 months old. In hope of keeping her nourished, when I left Cambodia in April I left enough for the second six months of formula.
As her growth chart clearly shows, she is in a dangerous state of malnutrition. For months we have been monitoring her and trying to work out what could be wrong. She was unwell about six weeks ago and Mum took her to hospital, who gave her “medicine” and arranged a follow up appointment at the end of June. Was she sick now? Apparently not. Was Mum making the bottles correctly? Apparently. It really seemed a mystery and various questions entered my head from afar, such as, were staff weighing her incorrectly, was Mum selling the cans of formula and feeding her inappropriately? Apparently not, to all of my imagined scenarios.
Finally our part time doctor, who spends his own money on patient treatments regularly despite being on a low salary, was able to review her. He can hear noises in her lungs and wants her to return to the hospital appointment with the weight chart, for review of probable Tuberculosis.
With TB diagnosed in the family a mere two years ago and this baby infected within the past five months, it is highly likely that the same person who unwittingly infected her sister, has this year also infected the baby. My colleagues went to great lengths to assist the family to an outpatient department for review in hope of identifying the source. So far her parents and siblings have all been cleared. Somewhere close, a grandparent, aunt, uncle or neighbour must be coughing TB. Assuming they have not sought medical attention, they very likely feel reasonably okay and have become accustomed to a chronic cough. I would love to be there with my Tuberculosis Investigator hat on, but I hope that by the time I do return, the source will have been identified and treated.
In a place where health services are not well coordinated, with all sorts of reasons that turning up unannounced and well (on face value) may not work, we have to wait now, for next week’s appointment, and hope that Mary comes home with anti-TB medications. She is the second baby in this community in a mere six months since I began working with them, that I know of, who has been or will be, commenced on anti-TB medications. According to World Health Organisation, in 2017, an estimated 1 million children became ill with TB and 230 000 children died of TB. With any luck little Mary will come out of this insidious situation, alive.
TB or not TB?
That is congestion.
Con-sumption be done about it?
Of cough! Of cough!
But it’ll take a lung, lung time…