Nutritional Rehabilitation

Presented by: Dr. KunalGuided by: Dr. Abhay Mudey

Contents

• Introduction• Nutritional interventions for malnutrition• Nutritional Rehabilitation

– Hospital based– Centre based– Community based

• Diets used in Nutritional Rehabilitation• References

Introduction

Definitions: Malnutrition is the condition that develops when the

 body does not get the right amount of the vitamins, minerals &other nutrients it needs to maintain healthy tissues  and organ function.

• Nutritional Rehabilitation:-Practical training to mothers of children with malnutrition in selecting, preparing food from locally available cheap sources and feeding them back to health.

Continued….

• Malnutrition has a detrimental impact on health, physical development, brain development, and intellect especially during pregnancy and the first two years of life.

• The consequences of malnutrition are higher child mortality and morbidity; lower cognitive development, hence lower returns from investments in education; and lower productivity leading to a higher burden to the health system.

• As calculated in a recent World Bank report, malnutrition accounts for an economic loss of about 3 percent of Gross Domestic Product in developing countries.

Nutritional interventions for malnutrition

• Nutritional Supplementation• Specific Nutrient Supplementation• Nutritional Therapy• Nutritional Rehabilitation• Nutrition Education

Types of Nutritional Rehabilitation

• Hospital based Nutritional Rehabilitation• Centre based Nutritional Rehabilitation

– Day Nutritional Rehabilitation centre– Residential Nutritional Rehabilitation centre

• Community based Nutritional Rehabilitation

Criteria for transfer to Rehabilitation phase

• Eating well• Mental state has improved: smiles, responds to

stimuli, interested in surroundings• Sits, crawls, stands or walks (depending on age)• Normal temperature (36.5 – 37.5 degree C)• No vomiting or diarrhoea• No oedema• Gaining weight: >5 g/kg of body wt per day for 3

successive days

Dietary Management

Diet should be:• From locally available staple foods• Inexpensive• Easily digestible• Consisting of minimum of 100 ml milk per day• Of cereal & pulse combination – 5:1 ratio• Evenly distributed throughout the day• Increase quantity of food which the child is

already used to• Increase number of feedings• Increase calorie by adding oil

Hospital based Nutritional Rehabilitation

• During rehabilitation phase – rapid catch-up growth in weight needs to be attained - facilitates early discharge & prevents secondary infections.

• Caloric intake of 170-220 Kcal/kg/day required for rapid catch up growth (WHO guideline).

• Rapid catch up growth - more than 10 g/kg/day.• Poor catch up growth – less than 5 g/kg/day (WHO

guideline).

Continued….

• Vitamin A and minerals to be supplemented– Hospital based nutritional rehabilitation of severely

undernourished children using energy dense local foods (Mamidi et al, Indian Paediatrics 2010;47:687-693)

• Child put on 100 kcal/kg/day initially• Increased upto 170-220 kcal/kg/day• Child fed every 2 hours initially and once appetite

improves, fed ad libitum.

Results

• mean gain – 5 g/kg/day.• Only 12% had rapid catch-up growth.• Higher morbidity score was associated with lower

rate of weight gain.

Centre basedNutritional Rehabilitati

on

Type A – Day Nutritional Rehabilitation centre

• For milder forms of protein energy malnutrition

• 6 to 8 hours / day, 6 days / week

• 3 daily meals• Mothers help prepare the

meals• Preference given to food

stuffs and utensils – familiar to the mothers & available in local market

• Not more than 30 children

SAT Medical college

• Department of Paediatrics, SAT hospital, Medical college, Trivandrum

• Cases referred from OPD, in-patient wards, peripheral hospitals and from ICDS network

• GOBIFFF (Growth monitoring, ORT, Breast feeding, Immunization, Food supplementation, Female education, Family health)

• SAT mix – a precooked, ready to mix cereal, pulse, sugar mixture

• For nutritional rehabilitation – SAT mix, coconut oil, vitamin and mineral supplements and family pot feeding

Type B – Residential Nutritional Rehabilitation centre

• For severe malnutrition – after treated in a hospital for complications

• Usually attached to a hospital• Children with mothers live in the institution• Mothers help to prepare the meals & receive

suitable instruction on child feeding – Educators of community

• Proper education and training to mothers can prevent relapses & prevent other children in same family from getting affected

Staffing and cost of NRCs

• Staffing Paediatrician – medical supervision• Public health nurse – administrative issues• Dietician – supervise dietary & catering• Part time welfare worker & health educator.

Objection to NRC

1) To provide clinical management & reduce mortality among children with severe acute malnutrition, particularly among those with medical complications.

2) To promote physical & psychological growth of children with severe acute malnutrition (SAM).

3) To build the capacity of mothers & other care givers in appropriate feeding & caring practices for infants & young children.

4) To identify the social factors that contributed to the child slipping into severe acute malnutrition

Failure of NRU in Tanzania

• Lack of knowledge of appropriate nutrition• Malnourished children identification – based on

clinical features (only severe PEM identified)• Children & other siblings back home – not

benefitted• Foods used in centre – not available back at home

--> PEM recurs• Community missed the opportunity of learning• Harsh treatment of parents at NRU

NRC, Davangere Medical college

• 1979 – International year of the Child – Nutritional Rehabilitation centre (NRC) started.

• Kitchen block of Chigateri General Hospital – used.

• Residential type of NRC• Village methods of preparing food adopted

– flat milling stones for grinding grains– flat baskets for cleaning the husk from grains– cooking on mud-fire place– use of earthen potteries

• Mother sleep on the floor with children• More real and they feel at home – higher success

rate of continuing same practice.

NRC, Davangere Medical college

• Davangere mix – Ragi hittu, roasted bengal gram powder, roasted groundnut powder and syrup of jaggery --> 100 gm ball – 14 gm protein and 400 calories.

• Mothers prepare Davangere mix and rice gruel.• Mothers – maintain cleanliness and work in

kitchen garden.• Mothers have practical nutritional and health

education.• Simple personal hygiene – taught to the children.• Health worker – teach school lessons to older

children.

Continued….

• Doctors (Paediatrics dept.) – health supervision• Children fed together with other children –

improve consumption• Occupancy – 10 to 12 malnourished children and

mothers• Average stay – 2 to 3 weeks• Average Cost – 1/10 of traditional hospital

treatment• Opportunity to educate Anganwadi worker, older

children, school teacher – influence community

Continued….

• Ample opportunity to teach mothers – prevent recurrence.

• Follow up study – 40 children for 6 -12 months• No recurrence or mortality• 50% had normal nutrition status and others grade

I malnutrition• None had micronutrient deficiency

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Community based Nutritional Rehabilitation (CBNR)

Community based Nutritional Rehabilitation (CBNR)

• Community based system of managing children who are developing PEM.

• Goal: to restore to near normal the nutritional status of the undernourished child and to have a sustained improved physical & mental growth, performance of the child , siblings & other children in the household.

Objectives:-

Short term:1) Early diagnosis & Treatment2) Prevent recurrence in treated child3) Prevent occurrence of PEM in the siblings & other

children Long term: To reduce PEM among children in the community

to a level whereby it is no longer a problem of public health.

Strategies

• Advocacy of CBNR to leaders from district down to community level --> facilitate establishment of CBNR & ensure its sustainability.

• Equipping health care providers & health workers with knowledge & skills on CBNR.

• Ensuring availability of necessary equipment & supplies for identification & categorization of malnutrition.

• Sensitizing & raising awareness of parents, care takers & community leaders on home rehabilitation

Identification of malnourished children

Place• Children attending

MCH clinic/ OPD• During village health

days & specific health campaigns

• Health checkups in nursery schools

• During home visits

Personnel• Health care provider• Health care providers,

village health workers• Teachers care

providers, village health workers

• Village Health workers , vilage health committees, parents / care givers , health care provider.

Check list for at risk children & households

• Insufficient household food security• Low birth weight (<2.5 kg)• Weight loss or no weight increase in children for 3

consecutive months• Household with h/o malnourished child• Deaths of under-5 children in same household• Lack of child spacing• Childhood orphanage• Single parent household• Drunkard-ness in the family

Community based nutrition promotion activities

• Improving food availability at household level – kitchen gardening– Finance– Job creation– Income generation by improving production & creation

of markets• Improving access to food by govt. help to obtain

sufficient water to grow– Supply of seed & plants– Supply of livestock for breeding

Continued….

• Improving utilization of food by improving knowledge on nutritious food groups– Demonstration of cooking– To build the skill of community health workers & support

groups

Diets used in Nutrition Rehabilitation

Milk based diet– High energy liquid diet– Good in hospital rehabilitation– Need for accurate dilution– Clean water required– Water content support bacterial growth– Immediate utilization

Ready to Use Food (RUTF) powder– Good in home rehabilitation– Oil based– No water– Does not support bacterial growth

Milk based diet

Bal-Ahar

• Developed at CFTRI, Mysore• Blend - Whole wheat flour (70 parts)

– groundnut flour (20 parts)– roasted Bengal gram flour (10 parts)– fortified with calcium salts and vitamins

• This contains about 20% proteins.• Daily supplement of 50 g of the food will provide

about 10 g proteins and substantial amounts of vitamin A, calcium and riboflavin

Hyderabad mix

• Developed at NIN, Hyderabad• Whole wheat -40 gm• Bengal gram – 16 gm• Groundnut – 10 gm• Jaggery – 20 gm• Total – 86 gm --> calories – 330 K cal/86 gm,

protein – 11.3 gm/86 gm

Indian Multipurpose Food (MPF)

• Developed at CFTRI, Mysore• Blend (75:25) of low fat 1:1 ground nut flour and

Bengal gram flour fortified with vitamins A and D, thiamine, riboflavin and calcium carbonate

• Three formulations: (i) seasoned; (ii) unseasoned and (iii) unseasoned with added skim milk powder’.

• A daily supplement of 25g MPF will provide about 10 g proteins and half the daily requirements of vitamin A, calcium and riboflavin.

Malt Food

• Developed at CFTRI, Mysore• Blend of cereal malt (40 parts), low groundnut

flour (40 parts), roasted Bengal gram flour (20 parts) and fortified with vitamins and calcium salts.

• Contains about 28% proteins• Daily supplement of 40 g of malt food will provide

about 10 g protein, and half the daily requirements of vitamin A, calcium and riboflavin

Kuzhandai Amudhu

• Blend of roasted maize flour (30 parts), green gram flour (20 parts), roasted groundnut (10 parts) and jaggery (20 parts)

• Developed by Sri Avinashilingam Home Science College for Women, Coimbatore

• 80 gm mixture• Food contains about 14.4% proteins• 80 gm food --> 11.5 g proteins and 305 K calories

Developmental stimulation

• Developmental stimulation has been found to be effective in malnourished children

• Objective: to stimulate the child through normal developmental channel and to prevent developmental delay

• Homed based stimulation is more cost effective• Components – developmental evaluation,

developmental information, individualized tasks for catch up, play therapy, motor co ordination tasks, training ADL

Continued….

• Nutritional management with developmental stimulation package – positive impact on growth and development

• To be integrated with existing ICDS programme

Developmental stimulation

• Developmental stimulation has been found to be effective in malnourished children

• Objective: to stimulate the child through normal developmental channel and to prevent developmental delay

• Homed based stimulation is more cost effective• Components – developmental evaluation,

developmental information, individualized tasks for catch up, play therapy, motor co ordination tasks, training ADL

Continued….

• Nutritional management with developmental stimulation package – positive impact on growth and development

• To be integrated with existing ICDS programme

Summery

• Information on catch up growth during nutrition rehabilitation of severely undernourished children reported from other countries is largely based on milk-based diets

• Moderate catch up growth can be achieved in severely undernourished children treated with energy dense local foods in a hospital setting

References

• Operational Guidelines On Nutrition Rehabilitation Centre (NRC)

• An Evaluation basedCommunity Based Management Of Sever Acute Malnutrition- International Center for Diarroheal Disease Research , Bangladesh

• Grigsby, Donna G., MD. "Malnutrition." eMedicine December 18, 2003. http://www.emedicine.com/ped/topic1360.htm.

• Recent Advances in Communinity Medicine- Suryakantha

• Text Book of Preventive social Medicine- Park 23rd Edition

“Give a child a meal you relieve his immediate hunger, teach his mother to feed him well and this will benefit him for

years”

Thank You