Nutritional Rehabilitation

Following is my Seminar Presentation on Nutritional Rehbilitation

1. Nutritional Rehabilitation Presented by: Dr. Kunal Guided by: Dr. Abhay Mudey

2. Contents Introduction Nutritional interventions for malnutrition Nutritional Rehabilitation Hospital based Centre based Community based Diets used in Nutritional Rehabilitation References

3. 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.

4. 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.

5. Nutritional interventions for malnutrition Nutritional Supplementation Specific Nutrient Supplementation Nutritional Therapy Nutritional Rehabilitation Nutrition Education

6. Types of Nutritional Rehabilitation Hospital based Nutritional Rehabilitation Centre based Nutritional Rehabilitation Day Nutritional Rehabilitation centre Residential Nutritional Rehabilitation centre Community based Nutritional Rehabilitation

7. 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

8. 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

9. 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).

10. 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 .

11. 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.

12. 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

13. 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

14. 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

15. Staffing and cost of NRCs Staffing Paediatrician – medical supervision Public health nurse – administrative issues Dietician – supervise dietary & catering Part time welfare worker & health educator.

16. Objection to NRC To provide clinical management & reduce mortality among children with severe acute malnutrition, particularly among those with medical complications. To promote physical & psychological growth of children with severe acute malnutrition (SAM). To build the capacity of mothers & other care givers in appropriate feeding & caring practices for infants & young children. To identify the social factors that contributed to the child slipping into severe acute malnutrition

17. 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

18. 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.

19. 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.

20. 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

21. 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

22. Community based Nutritional Rehabilitation (CBNR)

23. 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.

24. 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.

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. Milk based diet

32. 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

33. 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

34. 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.

35. 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

36. 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

37. 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

38. Continued…. Nutritional management with developmental stimulation package – positive impact on growth and development To be integrated with existing ICDS programme

39. 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

40. Continued…. Nutritional management with developmental stimulation package – positive impact on growth and development To be integrated with existing ICDS programme

41. 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

42. 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 23 rd Edition

43. “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