Malnutrition is endemic in children under 5 years  of age in many African countries, including The Gambia. Forty five percent of deaths in the under 5’s worldwide are related to malnutrition and there are long term health consequences for the survivors. Although the global trends in malnutrition have shown a decline since 1990, the rate of decline in sub-Saharan Africa has been slow. In The Gambia, the prevalence of malnutrition in the under 5’s was 11% in 2013. Although The Gambia is on target to meet the Millennium Development Goal 4 dealing with the reduction in child mortality by 2015, it is unlikely to meet the Millennium Development Goal 1 target of reducing  the number of children under 5 with malnutrition by 50%.
As in other sub-Saharan countries, the causes of malnutrition in children in The Gambia are numerous. Prevention and treatment strategies therefore, have to adopt a multidisciplinary approach, in order to alleviate this problem. Progress can only be accelerated when a coordinated and comprehensive approach by various agencies, including health, agriculture, social welfare, education, water and sanitation is fully implemented. The National Nutrition Agency (NaNA) is steering their national nutrition programmes in this direction. The role of MRC Keneba Nutrition Rehabilitation Centre (NRC)
The Nutrition Rehabilitation Centre (NRC) in Keneba is an integral part of the MRC Keneba Clinical Services. It is commonly known as the 'Keneba Supplement Centre' and was originally built with funds from the Catholic Relief Services in 1976.  In the early years, all children from 3 to 12 months were offered food supplements (made from wheat-soy blend, dried skimmed milk, sugar and oil) twice a day, 5 days a week. Weekly formal health education sessions on sanitation and how to make the food supplements, were also done by a midwife and offered to all mothers with children almost 12 months (Raycon-Solon, 2004). The centre was rebuilt in 2008/9 with funds from the MRC International Nutrition Group. It is now a 6-bedded centre that only admits children with severe acute malnutrition (SAM) or vulnerable children with moderate acute malnutrition (MAM) who are at risk of deteriorating to SAM. There are also a number of vulnerable children who return for regular reviews. The rainy season, from June to November, is the busiest period for the NRC. This is due to food scarcity, increased rates of diarrhoeal illness and other infectious diseases as well as increased farming activities by the mothers who often leave young children under the care of young carers or very elderly grandparents who are unable to provide adequate care and ensure appropriate feeding practices. The changes in treatment guidelines
The NRC uses the Gambia national guidelines for the management of SAM. Over the past decade the management of SAM in The Gambia has evolved in line with the WHO guidelines. In the early 1990’s therapeutic milk formulas (F-75 “starter formula” and F-100 “catch up formula”) were rolled out for the in-patient management of children with SAM. In the early 2000’s, “Ready to Use Therapeutic Food (RUTF)” was introduced into the SAM treatment protocols. This made it feasible for children with uncomplicated SAM to be managed in the community. In The Gambia, the community management of SAM uses RUTF (plump nut) supplied by the National Nutrition Agency (NaNA) took off in 2012 and is managed by the community health nurses (CHNs) with support from the nutrition field officers. Since then, the Keneba NRC has been able to discharge stable children with SAM to the CHN’s at an earlier stage in their treatment, which has enabled the carers to return home and continue caring for the other young children in the family.

The current strategies
In recent years the Supplement Centre has been treating up to 112 children per year, providing a comprehensive service to ill children with SAM, 7 days a week from 8am – 6pm, with the average duration of admissions being 2-6 weeks.

During this period, all carers are given a “hygiene pack” that contains medicated soap, towel, body cream, nail cutter, toothpaste and toothbrush for the child and more recently bar soap for washing clothes. Very often, carers who come from villages beyond Keneba, get little or no support from their families, making it a challenge to adhere to the appropriate hygienic practices that are advocated in the NRC. This is an initiative that is supported by funds from a Catholic church in Birmingham, UK.

In order to engage carers, on 3 afternoons a week, the carers are taught how to knit and crochet blankets/hats/warm clothes for their children to keep them warm especially during the nights, as children with SAM are susceptible to hypothermia. The surplus items are sold to visitors to the Keneba NRC, in order to raise funds for the sustainability of the initiative. In addition, as they recover, children have play therapy that includes stimulation using toys or baby massage sessions. The NRC staff and other members of the MRC Keneba clinical team, including the senior midwives also organise afternoon talks and workshops about nutrition, hygiene, food preparation and family planning. Moreover, groups and individual counselling sessions for carers, home visits and nutritional support are also organised for vulnerable children who have had several re-admissions for a variety of reasons. In this light, the NRC staff are all undertaking a communication skills course in health, in order to optimise their communication with carers and the infants.

The recent measures as well as our close working relationships with the CHNs have reduced the number of carers who have defaulted from NRC with their ill children, reduced the number of re-admissions and improved the morale of the carers and NRC staff. This year we have had visitors from UNICEF, NaNA and the Ministry of Health who have been very impressed with our initiatives and hope to introduce some of them to other nutrition rehabilitation centres in The Gambia.

Looking to the future
“Our ambitions for the future are to continue providing high standards of care 24 hours a day to children who present to the MRC Keneba NRC with SAM, working closely with NaNA/UNICEF/MoH; to be a centre of excellence for the management of SAM in children in The Gambia and to get involved in training other health care workers. We would also like to continue working closely with the community and government programmes in prevention strategies for malnutrition through education and accessing social and food support for vulnerable families with young children.” Says Dr Helen Nabwera, Career Development Fellow and Specialist Registrar in Paediatrics.