Addressing worsening infant malnutrition

Decades of war, conflict, and economic hardship have plunged millions of Afghans into extreme poverty and food insecurity.

Among the most vulnerable are infants, who face alarming rates of acute malnutrition. The shortage of professional medical services, combined with rising costs and limited humanitarian aid, leaves many families unable to provide lifesaving treatment. 

Amina has come to one of the Therapeutic Feeding Units supported by Action Against Hunger in a remote area of Badakhshan province with her baby boy. He is not yet six months old – but even for his young age, he is small and thin. His big eyes are starkly apparent against a skin that has darkened around them, and he is lying there calmly, not making a sound and moving as little as possible. 

This is Amina’s ninth child – her seventh surviving child. She has six older children. None of them had any trouble growing up, and she never had to bring them to a clinic. The youngest ones, however, showed signs of illness and undernourishment, and tragically Amina lost them both. When she started noticing the same symptoms in her infant son, she heard that a new clinic for children had opened a few hours away. So she decided to make the long journey, walking along a hot and dusty road for several hours with her baby to have him checked.

Arriving at the clinic, she is received by a nutrition assistant. She listens to Amina’s circumstances, examines, measures and weighs her baby. In consultation with the doctor, nurses and nutritional staff at the clinic, they determine not only the treatment necessary for her baby but also identify likely causes for the malnutrition to have appeared in the first place. This allows them to give Amina specific recommendations to avoid a relapse in the future. 

Malnutrition threatens the survival and development of children   

Amina’s story is one of many that our staff all over Afghanistan encounter every day. Data collected by our teams shows that over the first 10 months of 2024, over 85% of all children admitted to our therapeutic feeding units for treatment of severe acute malnutrition with complications were under 24 months old. This shows that most complicated cases occur during infancy, indicating a deteriorating malnutrition situation.  

The key aspect in reducing malnutrition in infants is to promote exclusive breastfeeding for children under six months. According to WHO, breastmilk provides all the energy and nutrients that the infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year. Additionally, breastfeeding can help protect babies against short-and long-term illnesses and diseases. While this may appear as an easy solution, ACF identified significant barriers to exclusive breastfeeding for children under six months in Afghanistan.

Economic hardships leave many families unable to provide enough food to make sure no one needs to go hungry. As mothers usually leave more food for their children, they are often the ones with the least food intake within their households, which can lead to malnutrition. In addition, in rural areas mothers are often busy with heavy physical work like agriculture and farming impending their ability to breastfeed their children.  

Poor coverage of health facilities across Afghanistan contributes to issues in treating babies when they are suffering malnutrition. In fact, 10 million people in Afghanistan live in so-called “white areas” where health facilities are more than a one-hour walking distance away. Walking for one hour or more may be impossible for those who are ill or weak. In fact, some caregivers must travel several hours to reach a facility, and these facilities may be understaffed and struggle to cope with the demand. In winter, many health facilities in Afghanistan are inaccessible due to high volume of snow (sometimes up to two meters high). In addition to the lack of public transport and the bad road conditions, as of this year, a Mahram rule has been imposed: women may only travel outside of their homes when accompanied by an immediate male relative (a husband, father or brother). If a mahram is not available, for example because they are busy working, then mothers cannot bring their children to health facilities.  

This is further compounded by the education bans on women, which leads to fewer female nurses, midwives and doctors available to counsel female patients. This may hinder pregnant and lactating women in accessing information on the benefits of exclusive breastfeeding and breastfeeding techniques. With fewer and fewer public spaces available for women and little opportunity for education around family planning, reproductive rights and professional child-care, women depend on the knowledge available in their immediate family. Various women asked reported not knowing anyone in their immediate community they could ask for guidance – they depend on health facilities to provide them with support, but many live far away from such facilities and cannot easily travel there. Traditional beliefs sometimes discourage mothers from exclusive breastfeeding and older members of the community often advise mothers to feed their baby with honey or butter. The reasoning behind this advice varies. Some communities believe that the first milk/clostrum is impure and harmful to the baby while others believe that the mother’s milk is not sufficient for the child. Companies and their promotion of formula milks available on the market often reiterate the latter. This is a growing issue of concern as our teams have observed increasing numbers of middle-class and educated families using formula milk. 

All these constraints mean that mothers in Afghanistan may face challenges properly feeding their young children.  

Action Against Hunger provides vital support to communities  

In each of its clinics, our teams provide not only screening services for all children and medical treatment for all cases found to suffer from moderate or severe acute malnutrition – it also provides a variety of surrounding services including community education and counselling sessions on best practices for caregiving. Community education may include awareness-raising amongst community elders on the benefits of exclusive breastfeeding for children.

Action Against Hunger supports, promotes and protects optimal nutrition services to treat instances of malnutrition. We provide health education on optimal feeding practices for children, often through child-friendly spaces with painted walls, cushions to sit and a variety of toys to choose from, as well as a private consultation room where nutrition and psycho-social counsellors work. All women whose children are admitted for treatment in the Therapeutic Feeding Unit are routinely scheduled in for a session with one of the counsellors. These serve first the important purpose of giving women a space to share their personal troubles – some of which may precisely be the root cause affecting their breastfeeding practices. According to psycho-social staff interviewed in three Therapeutic Feeding Units, most women report family challenges – including having too many children to feed – as their most pressing problem. However, graver problems may also be detected, including mental health conditions. Caregiving practice sessions may include childcare practices such as bathing, massaging and proper breastfeeding techniques where nutrition counsellors explain proper positions and feeding rhythms.  

We provide food assistance for caregivers of children with severe acute malnutrition, as well as cash assistance to households struggling to meet basic needs. Further livelihoods and economic opportunities for families are needed to end the cycles of malnutrition – a topic addressed by our experts through programs in several provinces. 

However, there are further actions needed to properly address the underlying causes of malnutrition in young children. Education on proper feeding and care practices should be rooted at community level, engaging a wide array of local stakeholders – including local health care workers, religious leaders, village elders and other influencers. Where relevant, discussions with stakeholders on how to improve health and nutrition outcomes, including on health policies, are needed . 

Illustrations: © Farhad Rouhani Moghadam for Action Against Hunger supported by German Federal Foreign Office (GFFO)