Annals of Community Health (ISSN 2347-5455, eISSN 2347-5714), Peer Reviewed, Indexed Journal focusing exclusively on Community Medicine and Public Health

Nutritional Rehabilitation

Plan of presentation

  • Introduction
  • Nutritional interventions for malnutrition
  • Nutritional Rehabilitation
    • Hospital based
    • Centre based
    • Community based
  • Diets used in Nutritional Rehabilitation
  • References


  • 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 Intervention for Malnutrition

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

Nutritional Therapy

Follow up study @ ICH – 1/3 of malnourished children treated in hospital – were dead within a year, still others malnourished

Nutritional Rehabilitation

Dr. Jose M. Bengoa of South America (chief, Nutrition unit, WHO, Geneva) – 1955.

Novel concept in the management of protein energy malnutrition “To get well and to keep well”.

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

Chinese proverb: “Give a man a fish, you feed for a day, teach a man to fish, you feed him for life”

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

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).
  • 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.


  • 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 based Nutritional Rehabilitation

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 (Polak study & Raoult study)
    • Paediatrician – medical supervision
    • Public health nurse – administrative issues
    • Dietician – supervise dietary & catering
    • Part time welfare worker & health educator.

Objection to NRC

  • Scattered rural population – type B preferred
  • Effective coverage is small
  • Cost of the programme
  • Child is prone to infection & all malnourished children under a single roof (Type B)
    • Problems of utilization of Nutritional Rehabilitation by mothers of malnourished children in Chad Djamena et al study
    • High % of withdrawal – nearly 1/3rd
    • The quest of therapy takes on pilgrimage from one health facility to another until they arrive at NRC.
    • Referral system is not well established
    • Duration of treatment – too long.
    • No follow up guaranteed
    • Waiting time for supplement
    • Lack of drugs & poor quality of porridge
    • Service staff show them no respect.

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.
  • 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
  • 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

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.


  • Short term:
    • Early diagnosis & Treatment
    • Prevent recurrence in treated child
    • 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.


  • 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

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

  1. Improving food availability at household level – kitchen gardening
    • Finance
    • Job creation
    • Income generation by improving production & creation of markets
  2. Improving access to food by govt. help to obtain sufficient water to grow
    • Supply of seed & plants
    • Supply of livestock for breeding
  3. 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


  • 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
  • Nutritional management with developmental stimulation package – positive impact on growth and development
  • To be integrated with existing ICDS programme

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