Plan of presentation
- Introduction
- Nutritional interventions for malnutrition
- Nutritional Rehabilitation
- Hospital based
- Centre based
- Community based
- Diets used in Nutritional Rehabilitation
- References
Introduction
- 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.
Result:
- 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.
Objectives:
- 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.
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
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
- 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
- Nutritional management with developmental stimulation package – positive impact on growth and development
- To be integrated with existing ICDS programme
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