There is no data to support the theory that child malnutrition is increasing or decreasing yet. But experts agree that a surge is coming, writes Sarah Evans and Kyle Cowan.
A surge in child malnutrition cases in the coming months is inevitable, experts have warned, although the data to support the theory that there has been a Covid-19-linked increase in child malnutrition is not there yet.
Child nutrition rose to the news agenda last week when the South African Medical Research Council's CEO, Dr Glenda Gray, claimed in an interview with News24 that child malnutrition was increasing at Chris Hani Baragwanath academic hospital.
Gray initially said there had been no cases of child malnutrition there for a decade, but later backtracked to say that there was a spike in early May that needed to be monitored.
In a statement a few days later, minister of health Zweli Mkhize took issue with Gray's initial claim and said that malnutrition had actually decreased in March and April at the hospital compared to the previous four years.
Mkhize said: "There has been a reduction in the number of cases of malnutrition that have been seen at Chris Hani Baragwanath Academic Hospital POPD and the total admissions during the month of March and April 2020, when compared to the previous four years. To illustrate this, in April 2019 there were 2885 patients seen and 500 admissions. However, in April 2020 there were 834 patients seen and 146 admissions."
News24 asked the Gauteng department of health to clarify the issue.
The department provided a document compiled by Professor Sithembiso Velaphi, head of paediatrics at Chris Hani Baragwanath hospital, showing exactly the same numbers that Mkhize quoted.
The figures show that, in March and April 2019, there were 2 731 and 2 885 cases of "malnutrition" at the hospital. In 2020, there were 2 266 and 834 "malnutrition" cases for the same period.
News24 asked the department for clarity - do the numbers show child malnutrition or malnutrition including adults?
Are these children diagnosed with Severe Acute Malnutrition (SAM), which typically results in hospitalisation, or milder forms of malnutrition?
In response, the department said the document emanated from the paediatrics department and that the number reflected "malnutrition" cases.
Gray's early May increase was not reflected in the numbers provided by the department.
Who is right?
So was Gray right, or was Mkhize? Is child malnutrition increasing or not at the hospital?
Technically speaking, neither, says Professor Haroon Saloojee, head of community paediatrics at Wits University and clinical unit head at Chris Hani Baragwanath hospital.
There is not data - yet - to support the claim that severe malnutrition admissions have spiked or decreased because of the lockdown.
Fewer cases may have been recorded at Chris Hani Baragwanath in March and April compared to previous years, but with admissions generally being down for the period, for a variety of reasons, any dip in child malnutrition cases is impossible to interpret.
Mkhize's numbers are right, but it is too soon to draw the inference from them that Gray's second statement was wrong.
The brief spike in cases recorded in the first week of May was so marginal that nothing can be read into it, Saloojee says, and the average number of cases went right back to what it was in March and April for the remainder of May.
The true numbers will only be known once children who went hungry during the two month hard lockdown start arriving at the hospital.
But regardless of their disagreement, experts agree that a spike in Severe Acute Malnutrition (SAM), the most severe and sometimes fatal form of malnutrition, will come as no surprise.
Not only will millions of families already living in poverty have lost the income during the hard lockdown, but state support specifically for the nutritional needs of children under the age of five has been inadequate, experts have warned.
Healthcare workers are also worried about less serious instances of malnutrition, as the slide from a moderate case to an acute one can happen in the space of a few weeks.
Over half a million children reported not having enough food in 2017, according to Stats SA.
Lori Lake, a researcher at the Children’s Institute at the University of Cape Town, said Gray was right to bring attention to the issue.
She said that children are particularly vulnerable during the lockdown if their parents can’t work, as grants and food parcels are not sufficient.
Access to healthcare for children has also been affected, she said, meaning that keeping tabs on malnutrition is also affected. Children who are normally monitored with every healthcare visit are not going to hospitals.
This could be for a variety of reasons, for example, because their parents perceive hospitals to not be safe or because of reduced public transport.
About nine million children from the poorest households rely on the national school feeding scheme for nutrition - a scheme, which for two months has been cancelled.
An increase in the child support grant was initially hoped in that it would also help poor households with children cope with a loss of income, but the increase applies per caregiver applying for the grant, not per child in the household.
Government community healthcare workers who ordinarily do home visits for many children under the age of two have since been redeployed as part of government's Covid-19 screening programme, making the situation more difficult to track.
Without a substantial survey on the go, healthcare experts say the country will only get a glimpse of the current child malnutrition numbers once the most severe cases of malnutrition result in hospital admissions.
According to Saloojee, about 85% of all SAM cases do not require hospital admission. What tends to "push them over the edge" is when the child develops an infection, prompting a caregiver to bring the child to the hospital.
"My fear is that they (malnourished children) might be dying at home," he said. A hungry child could develop SAM within a few weeks.
Considering that lockdown started in March, Saloojee estimates that hospitals will start seeing SAM cases from now on.
Stunting or wasting
Malnutrition in children takes three forms: being underweight is the least severe kind, while "stunting" is when children do not grow properly and are short.
Stunting is often a sign of chronic malnutrition and is generally irreversible.
In many cases, stunting starts in utero, causing many experts to raise the alarm about interventions specifically for pregnant women during Covid-19.
In South Africa, about a quarter of all children are stunted. The condition can have severe neurological and other developmental consequences for children.
SAM, also grimly known as "wasting", is the most severe form of malnutrition and about 8% of children with SAM die.
Professor Peter Cooper, Professor emeritus at the department of paediatrics and child health at Wits University and clinical head of Charlotte Maxeke academic hospital, says small children and pregnant women are extremely vulnerable.
"There's so many people depending on handouts for food now; there can be no doubt that there will be children who will be going hungry," he says.
"Two months (without proper nutrition) is a long time in pregnancy. For adults, it (malnutrition) may not cause a severe reaction but it will cause big problems for a pregnant woman."
Babies, small children and pregnant women have specific nutritional needs, he says.
Ignorance about what kinds of foods small children need is already a problem, and is the cause of some SAM cases, according to Cooper, although poverty is the cause of the vast majority of cases.
Professor Julian May, Director of the Centre of Excellence in Food Security at the University of the Western Cape, says the nutrition of pregnant women and newborns during lockdown is not receiving enough attention.
Stunting is a real worry for experts now, he says.
"The reason we worry about stunting is not that the children will be short, but because of what it signals about the development of the rest of the child’s body. Stunting influences the development of a child’s immune system," he says.
"You are stunted for life. It is not reversible."
The nutritional status of mothers is critical during the third trimester of pregnancy, he says, as the child's body develops rapidly in the womb.
There is a high risk of the child being born underweight without the mother having proper nutrition and this places the child at risk of being stunted if the situation is not addressed.
In the first 1 000 days of the child's life, the risk of stunting can be reversed but only if urgent attention is given to the child's nutritional needs.
There is also concern that, as fewer people frequent clinics and hospitals, pregnant women among them are not going for their antenatal check ups and not receiving state-supplied antenatal supplements.
And "piecemeal" solutions, according to a community healthcare activist with over 20 years experience working with mother and child health, is not going to solve the problem.
"Stunted children become overweight children. We fill them up with bad foods. Our children are short and fat. They are undernourished and they will also get sick and die," she says.
In the short-term, some healthcare experts suggest instructing the Covid community healthcare workers to do a mid-upper arm circumference measurement on all children under the age of five at the households they visit for Covid screening, for a bare minimum assessment of their weight.
Others have stressed that a child-specific food package must be supplied by government after consultation with experts in child nutrition.
A spokesperson for the South African Social Security Agency (Sassa) did not respond to a request for comment about the suitability of its food parcels for children.
- Evans and Cowan are investigative reporters at News24
*The original version of this story said that Mkhize did not specify whether the malnutrition numbers referred to children or not, but it was later pointed out that the data he referred to came from the paediatrics outpatients department at Chris Hani Baragwanath Hospital. The story has been amended to reflect this. News24 regrets the error.