The document discusses the Janani Shishu Suraksha Karyakram (JSSK) program and Nutritional Rehabilitation Centres (NRCs) in India. The JSSK aims to provide free healthcare for pregnant women, newborns, and infants up to 6 months. The NRC provides treatment for children ages 6-59 months with severe acute malnutrition. Services at NRCs include medical care, therapeutic feeding, counseling, and follow-up to help treat malnutrition. Performance is assessed based on recovery rates, death rates, and other indicators. The document outlines admission criteria and exit indicators for evaluating children in NRCs.

1. Janani Shishu Suraksha Karyakram (JSSK)
and
Nutritional Rehabilitation Centre
Dr Rekha Thaddanee

3. OBJECTIVES
– Eliminating out-of-pocket expenses for families of pregnant
women, sick newborns and infants in government health
facilities
– Reaching the unreached pregnant women (nearly 75 lakh a year
who still deliver at home)
– Timely access to care for sick newborns

4. – Free and cashless delivery
– Free C-section
– Free drugs and consumables
– Free diagnostics
– Free provision of blood
– Free diet during stay in health institutions
Up to 3 days for normal delivery
7 days for Caesarean sections
– Free transport
 Home to health institution
Between health institutions in case of referral
Drop back home after delivery
– Exemption from all kinds of user charges, including for
seeking hospital care up to 6 weeks post delivery (for
post natal complications)

5. – Free treatment at the public health institutions
– Free drugs and consumables
– Free diagnostics
– Free provision of blood
– Exemption from all kinds of user charges

7. Nutritional Rehabilitation Centre

8. Nutrition Rehabilitation Center
• Nutrition Rehabilitation Center (NRC) is a unit in
a health facility where children with Severe Acute
Malnutrition (SAM) are admitted and managed.
Children are admitted as per the defined admission
criteria and provided with medical and nutritional
therapeutic care.

9. Objectives of NRC
1. To provide clinical management
2. Reduce mortality among children with severe
acute malnutrition, particularly among those
with medical complications.
3. To promote physical and psychosocial growth of
children with severe acute malnutrition
4. To build the capacity of mothers and other care
givers in proper feeding and caring practices for
infants and young children
5. To identify the social factors that contributed to
the child slipping into severe acute malnutrition.

10. Services provided at the NRC
1. 24 hour care and monitoring of the child
2. Treatment of medical complications
3. Therapeutic feeding
4. Providing sensory stimulation and emotional care
5. Counseling on appropriate feeding, care and hygiene
6. Demonstration and practice- by -doing on the
preparation of energy dense child foods
7. Using locally available, culturally acceptable and
affordable food items
8. Follow up of children discharged from the facility.

11. Human resources at NRC
Requirement for the smooth functioning of a 10
bedded NRC is as follows:-
1. Medical officer - One
2. Nursing staff - Four
3. Nutrition counsellor - One
4. Cook cum Care taker - One
5. Attendant/ cleaners - Two
6. Medical social worker - One

12. The NRC should have the following:
• Patient area to keep the beds; in NRC adult
beds are kept so that the mother can be with
the child.
• Nursing station

13. The NRC should have the following:
Play and counselling area with toys; audiovisual
equipment like TV , DVD player and IEC material.

14. The NRC should have the following:
• Kitchen and food storage area attached to
ward, or partitioned in the ward, with enough
space for cooking, feeding and demonstration.

15. The NRC should have the following:
• Attached toilet and bathroom facility for
mothers and children along with two separate
hand washing areas.

16. Admission Indicators in NRC
• New admission: patient who has never been
admitted before in NRC
• Re-admission: a defaulter who has admitted
back to the NRC within 2 months
• Relapse: a patient who has been discharged
as cured from the NRC within the last 2
months but is again eligible for admission to
NRC. A large number of relapses are often a
sign of food insecurity.

17. Exit Indicators in NRC
• Exit indicators provide information about the
proportion of patients completing the
treatment successfully or not successfully
(recovered , defaulter, death). They are
calculated as a percentage of the total number
of exits (discharges) during the reporting
month.

18. Exit Indicators in NRC
• Recovery (cured) rate: Number of beneficiaries
that have reached discharge criteria within the
reporting period divided by the total exits
• Defaulter rate: Number of beneficiaries that
defaulted during the reporting period divided by
the total exits
Defaulter will be a child with SAM admitted to
the ward but absent (from the ward) for three
consecutive days without been discharged.

19. Exit Indicators in NRC
• Non-respondent: This exit category includes
those beneficiaries who fail to respond to the
treatment
When the number of cases in this category is
high it may indicate underlying problems
related to the patient (e.g. chronic disease) or
to the programme, and need to be addressed.

20. Performance of NRCs may be assessed by these
criteria
Indicators Acceptable Not Acceptable
Recovery rate >75% <50%
Death rate <5% >15%
Defaulter rate <15% >25%
Weight gain(g/kg/d) >=8 gm <8gm
Length of stay (weeks) 1-4 <1 or >6

21. NRC
• Wage Compensation- Rs. 100/day
• For transport- Rs. 200
• Total for 14 days stay- Rs. 1600
• For each followup (three visits)- Rs. 300
• Total expense on one child- Rs. 2500
• Food for mother/care giver also

22. NRC
• ASHA incentives: Incentives of Rs. 50 can be
provided to ASHA for accompanying the child to the
NRC and motivating the mother to stay for at least
14 days till the child is stabilized and has started to
eat. Additional incentive of Rs. 50 may be given for
each follow up visit by the child, up to a maximum
of three visits.

23. Criteria for admission in NRC for Children
Between 6-59 months age
• SAM is defined as the presence of
1. Severe wasting
2. Weight for height/length < - 3SD and or
3. MUAC < 11.5 cm and or
4. Presence of bilateral pitting edema
• Children with SAM have nine times higher risk
of death

24. Severe wasting

25. Nutritional bilateral pitting edema

26. MUAC

27. MUAC

28. SAM

29. Criteria for admission in NRC for
Children 6-59 months age
• WITH Any of the following complications:
1. Anorexia (Loss of appetite)
2. Fever or Hypothermia
3. Persistent vomiting
4. Severe dehydration based on history and clinical
examination
5. Not alert, very weak, apathetic, unconscious,
convulsions
6. Hypoglycemia

30. Criteria for admission in NRC for
Children 6-59 months age
7. Severe Anemia (severe palmar pallor)
8. Severe pneumonia
9. Extensive superficial infection requiring IM
injections
10. Any other general sign that a clinician thinks
requires admission for further assessment or
care
11. In addition to above criteria if the caregiver is
unable to take care of the child at home, the
child should be admitted.

31. Criteria for admission in NRC for
Infants < 6 months
• Infant is too weak or feeble to suckle effectively
(independently of his/her weight-for-length).
or
• WfL (weight-for-length) <–3SD (in infants >45
cm)
or
• Visible severe wasting in infants <45 cm
or
• Presence of edema both feet

32. EPIDEMIOLOGY
• Worldwide, SAM is among leading causes of
death among children <5Yrs
• More common in the developing states
• Malnutrition causes abt 5.6 to 10 million
deaths/yr, with sever malnutrition
contributing to abt 1.5 million of these deaths.

33. ETIOLOGY
• Primary - when the otherwise healthy
individual's needs for protein, energy, or both
are not met by an adequate diet. (most
common cause worldwide)
• Secondary - result of disease states that may
lead to sub-optimal intake, inadequate
nutrient absorption or use, and/or increased
requirements because of nutrient losses or
increased energy expenditure.

34. PRECIPITATING FACTORS
 Lack of food (poverty)
 Inadequate breast feeding
 Wrong concepts about nutrition
 Diarrhoea & malabsorption
 Infections (worms, measles, T.B)

35. WHO classification
Acute malnutrition
(severity)
MUAC (cm) WHZ
None >13.5 >-1
At risk 12.5 to 13.4 -2 to -1
Moderate 11.5 to 12.4 -3 to -2
Severe
<11.5 <-3
Kwashiorkor

36. PATHOPHYSIOLOGY of SYMPTOMS
OEDEMA
Cause:
• Protein-deficient, hypoalbuminaemia, reduced plasma oncotic
pressure, fluid shift to interstitium
• Free radical damage of cell membrane, Na+/K+ ATPase
malfunction- fluid leaks
• Hypovolemia, reduced GFR, activation of RAAS, Na+ and water
retention.
• Increase levels of leukotrienes cause uncontrolled vasodilation-
hypovolemia-low BP-decrease peritubular hydrostatic pressure –
increase tubular reabsorption of salt and water.

37. PATHOPHYSIOLOGY Cont’d
WASTING
• Calorie def – fats and tissue proteins mobilized to
supply energy for metabolic processes.
• Recurrent infections coupled with hypoglycemia
cause acute stress response- cortisol released-
wasting
• Effects of associated infections e.g. HIV wasting
syndrome

38. PATHOPHYSIOLOGY- Cont’d
HAIR CHANGES
• Keratin synthesis impaired because of cysteine and
methionine def , thus brittle hair easily pulled off
/breaks
• Pigment melanin formed from tyrosine so it’s deficiency
in kwash. Hair colour changes reddish or grey.
• Periods of good nutrition alternating with poor
nutrition- flag sign.
• Dullness and lack of lustre due to weathering of the hair
cuticle.

39. • Flag sign

40. PATHOPHYSIOLOGY- Cont’d
SKIN CHANGES
•Ulcerations and flaky paint rash due to Zn
def.
•Atrophy of sweat and sebaceous glands
leads to excessive dryness of the skin.
•Hyperpigmentation, erythema, duskiness
of exposed areas – niacin def
•Cracking and fissuring of hyper pigmented
•Generalized hypopigmentation due to
stretching of the skin by the edema.

41. Ulcerations and flaky paint rash due to
Zn deficiency

42. PATHOPHYSIOLOGY- Cont’d
HEPATOMEGALY/ FATTY LIVER
– Free radicals damage mitochondrial enzymes in the liver
causing reduced synthesis of proteins.
– Beta LP def – accumulation of TG in the liver – fatty liver –
Hepatomegally.

43. PATHOPHYSIOLOGY- Cont’d
POT BELLY
– Hypotonic muscles of
abdominal wall resulting
from muscle wasting.
– Overgrowth of bacteria
in the gut due to
reduced immunity-
– Paralytic ileus due to
hypokalemia
– Hepatomegally because
of fatty liver

44. PATHOPHYSIOLOGY- Cont’d
DIARRHOEA
• Caused by recurrent infections due to reduced
immunity- low secretary IgA and reduced
secretion of acid in stomach.
• Malabsorption – deficiency of pancreatic
enzymes resulting from pancreatic
atrophy/protein deficiency.
• Villous atrophy- reduced absorptive surface

45. PATHOPHYSIOLOGY- Cont’d
Recurrent infections
• Atrophy of thymo-lymphatic glands cause
depletion of T lymphocytes and depressed CMI
thus infections like Herpes, candidiasis common.
• Reduced phagocytic and bactericidal activity of
leucocytes- NADPH oxidase and lysozyme def
• C3,C5, and factor b levels reduced – opsonization
and phagocytosis reduced.
• Immune response reduced due to inability to
synthesis IL-1,IL-6, TNF alpha due to lack of
supply of essential AA.

46. PATHOPHYSIOLOGY- Cont’d
The “Vicious Cycle”of Undernutrition & Infection
Disease:
. incidence
.severity
.duration
Appetite loss
Nutrient loss
Malabsorption
Altered metabolism
Inadequate dietary intake
Weight loss
Growth faltering
Lowered immunity
Mucosal damage
Figure 2. The Synergistic cycle of infection and malnutrition

47. PATHOPHYSIOLOGY- Cont’d
ANAEMIA
• Due to dietary deficiency of iron and
folate
• Parasitic infections e.g. hookworm.
• Malabsorption due to recurrent diarrhea.
• Reduced protein intake and synthesis.

48. PATHOPHYSIOLOGY- Cont’d
APATHY
• Hypokalemia- muscle weakness and easy fatigability of muscles-
child lacks in energy
• Lack of stimulation and deprivation causes reduced growth of
brain and nerve thus mental slowing.
• Reduced BMR
• Apathy also attributed to Zinc deficiency.

49. PATHOPHYSIOLOGY- Cont’d
ELECTROLYTE/ MINERAL DEFICIENCIES –
Magnesium
• Good evidence that magnesium deficiency is common in
severe malnutrition
• Consequences:
– Muscular twitching
– Arrhythmias
– Convulsions
– Predisposes to K+ deficiency

50. PATHOPHYSIOLOGY- Cont’d
sodium
– Plasma sodium can be low and on occasions is
extremely low in children with marasmic
kwashiorkor.
• However total body sodium is often increased

51. PATHOPHYSIOLOGY- Cont’d
Consequences of Zinc deficiency
• Reduced appetite
• Reduced immunity
• Reduced gastrointestinal function – longer period of diarrhoea
• Reduced ability to gain weight even when there is adequate
feeding
• Skin changes
• Acrodermatitis Enteropathica

52. Zinc deficiency

53. PATHOPHYSIOLOGY- Cont’d
Consequences of Copper and Selenium deficiency
• Copper is required for adequate tissue growth
and repair, anaemia and poor bone growth may
be associated with inadequate copper (it is very
little in milk).
• Selenium deficiency may be associated with
reduced cardiac muscle function.

54. PHYSICAL EXAMINATION
• Shock: lethargic or unconscious; with cold
peripheries, slow cap refill (>3sc) or weak
rapid pulse or low BP
• Signs of Dehydration
• Severe pallor
• Bilateral pitting edema

55. PHYSICAL EXAMINATION
• Eye signs of vitamin A deficiency
– Dry conjuctival or cornea, Bitot spots
– Corneal ulceration
– Keratomalacia
In Vitamin A deficiency- pt likely to be photophobic,
keep eyes closed. Examine eyes gently to avoid
corneal rupture.

56. Bitot spot

57. Keratomalacia

58. PHYSICAL EXAMINATION
• Localizing signs of infection: ear discharge,
throat infections, skin infections or
pneumonia
• Signs of HIV infection
• Fever : >37.5 c or Hypothermia (rectal: <35.5c)
• Mouth ulcers

59. PHYSICAL EXAMINATION
• Skin changes
– Hypo/hyperpigmentation
– Desquamation
– Ulceration
– Exudative lesion

60. Features of Kwashiorkor
1.Always present
• Generalized edema, Pitting edema over the
lower limbs
• Growth failure: wasting (may be masked by
edema).
• Psychomotor changes: apathy, irritability

61. Features of Kwashiorkor
2.Usually present
• Hair changes: fine but coarse in chronic d’se,
easy pluckability, discoloured, light-colored
hair streaky red/gray, sparseness (areas of
alopecia),Alternate areas of hypo and normal
pigmentation-flag sign
• Anemia
• Loose stools

62. Features of Kwashiorkor
3.Occasionaly present
• Hepatomegaly
• Signs of vitamin deficiencies
• Skin changes
A. Diffuse/patchy areas of hypo/hyperpigmentn
B. Thin, shiny, taut skin over edematous areas
C. Moist ulcerations over flexural/pressure
points

63. Features of Kwashiorkor
Classical skin lesions
– Flaky paint dermatosis: hyper pigmented,
desqumation area (flake) over raw skin.
– Crazy pavement dermatosis: dry, hyperkeratotic
,fissured skin with alternate areas of hyper/hypo
pigmentation
– Mosaic dermatosis: mixed lesions in mosaic form

64. Flaky paint dermatosis

65. • Mosaic
dermatosis ↓

66. Features of Marasmus
1.Always present
• Extreme growth failure, <50% WA
• Marked muscle wasting, loss of subcut fat
• Alert, with good appetite

67. Features of Marasmus
Face is shriveled like ‘little old man, monkey like-
Relatively larger head, wrinkled skin, loose skin
folds over buttocks, thighs, axilla

68. Features of Marasmus
2.Occasionaly present
• Anemia
• Diarrhea with signs of dehydration
• Vit deficiencies: cheilosis, dermatosis, rickets
• Infections: TB, measles

69. Laboratory Tests
• Blood glucose
• Haemoglobin
• Serum electrolytes eg; (sodium, potassium, and calcium whenever
possible)
• Screening for infections: Total and differential leukocyte count,
blood culture
• Urine routine examination and Urine culture
• Chest x-ray
• Mantoux test
• Screening for HIV after counseling
• Any other specific test required based on geographical location or
clinical presentation e.g. Celiac Disease, malaria etc.

70. SAM
Principles of management of SAM are based
on 3 phases:
• Stabilization Phase
• Transition Phase
• Rehabilitative Phase

71. Stabilisation Phase
• Children with SAM without an adequate appetite and/or a
major medical complication are stabilized in an in-patient
facility
• This phase usually lasts for 1–2 days
• The feeding formula (F-75) used during this phase is Starter
diet which promotes recovery of normal metabolic function
and nutrition-electrolytic balance
• All children must be carefully monitored for signs of
overfeeding or over hydration in this phase.

72. Transition Phase
• This phase is the subsequent part of the stabilization phase and
usually lasts for 2-3 days.
• The transition phase is intended to ensure that the child is clinically
stable and can tolerate an increased energy and protein intake
• The child moves to the Transition Phase from Stabilization Phase
when there is:
At least the beginning of loss of oedema
AND
Return of appetite
AND
No nasogastric tube, infusions, no severe medical problems
AND
Is alert and active

73. Transition Phase
• The ONLY difference in management of the child
in transition phase is the change in type of diet.
• There is gradual transition from Starter diet (F-
75) to Catch up diet (F 100).
• The quantity of Catch up diet (F100) given is
equal to the quantity of Starter diet given in
stabilization Phase.

74. Rehabilitation Phase
• Once children with SAM have recovered their appetite
and received treatment for medical complications they
enter Rehabilitation Phase.
• The aim is to promote rapid weight gain, stimulate
emotional and physical development and prepare the
child for normal feeding at home
• The child progresses from Transition Phase to
Rehabilitation Phase when: has reasonable appetite;
finishes > 90% of the feed that is given, without a
significant pause
• Major reduction or loss of oedema
• No other medical problem

75. Management
• Those who pass appetite test: phase 2
treatment in NRC using F 100 and locally made
special feed for uncomplicated SAM.
• Those who fail appetite test and with one or
more danger signs or with medical conditions
requiring admission- phase 1 treatment in
NRC

76. APPETITE TEST FEED (EPD)
• Roasted ground nuts 1000 gm
• Milk powder 1200 gm
• Sugar 1120 gm
• Coconut oil 600 gm
• How to prepare:-
------------

77. How to prepare EPD
• Take roasted ground nuts and grind them in mixer
• Grind sugar separately or with roasted ground nut
• Mix ground nut, sugar, milk powder and coconut oil
• Store them in air tight container
• Prepare only for one week to ensure the quality of feed
• Store in refrigerator

78. How to do appetite test?
• Do the test in a separate quiet area
• Explain to the mother/caregiver
how the test will be done
• The mother/caregiver should
wash her hands
• The mother sits comfortably with
the child on her lap and offers
therapeutic food

79. How to do appetite test
•The child should not have taken
any food for the last 2 hrs
•The test usually takes a short time
but may take up to one hour
•The child must not be forced to
take the food offered
•When the child has finished, the
amount taken is judged/ measured

80. APPETITE TEST
Appetite test is fail if baby is not eating that much
amount of EPD according to weight----
• BW(Kg) EPD
• 3-3.9 <15gm
• 4-6.9 <20gm
• 7-7.9 <25gm
• 8-9.9 <30gm
• 10-11.9 <35gm
• 12-14.9 <40gm

81. 10 step management of SAM
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Electrolyte imbalance
5. Infections
6. Micronutrient def.s
7. Initial feeding
8. Catch up growth
9. Sensory stimulation
10. Follow up

82. 10 step approach
STABILIZATION REHABILITATION
DAY 1-2 DAY 3-7 WEEKS 2-6
Hypoglycemia -------------
Hypothermia -------------
Dehydration -------------
Electrolyte imbalance ---------------------------------------------------------------------
Infections ----------------------------------
Micronutrient ------NO IRON-----------------------WITH IRON------------
Initiate feeding -----------------------------------
Catch up growth ---------------------------
Sensory stimulation --------------------------------------------------------------------
Prepare for follow-up ---------------------------

83. Hypoglycemia
Dx: blood glucose < 54mg%
• Rx: if conscious child
– 50mls of 10% glucose or sucrose sol (1 rounded
teaspoon of sugar in 3.5 tsf of water) orally or by
NGT, followed by 1st feed.
– Give 1st feed of F75 therapeutic milk every 30 min
for first 2 hours then F75 feeds 2hrly day and
night.

84. Hypoglycemia
– If unconscious child: Rx with IV 10% glucose at
5mls/kg or if no IV access then 10% glucose by
NGT
• Monitoring: after 30 mins. If BG still <54mg% repeat
10% dextrose bolus.
• Then repeat 2 hourly.

85. Hypoglycemia
• Keep child warm as hypoglycemia and
hypothermia coexist
• Administer antibiotics as hypoglycemia may
be a feature of underlying infection

86. Hypothermia
• Often indicates coexisting hypoglycemia or
serious infection
• Dx: Axillary temp <35oc rectal <35.5oc
• Rx:
– Feed immediately and then 2hrly unless with abd
distension
– Dress warmly-cover with a warmed blanket
– Keep dry, away from draught
– Heaters or lamp
– Put child on mothers bare chest or abdomen(KMC)
– Avoid exposure to cold during procedures, bathing

87. Hypothermia
• Monitoring:
– Monitor temp 2hrly- rectal till rises to 36.5oc,half
hourly if heater is being used.
– Ensure child is covered at all times
– Check for hypoglycemia
• Prevention
– Feed 2-3hrly
– Kangaroo technique
– Avoid child exposure to cold
– Don’t use hot water bottle of fluorescent lamp
– Change wet nappies

89. Severe Hypothermia
• If rectal temperature < 32°C
• Give warm humidified oxygen.
• Give 5 mL/kg of 10% dextrose IV immediately or
50 ml of 10% dextrose by nasogastric route (if
intravenous access is difficult).
• Provide heat using radiation (overhead warmer),
or conduction (skin contact) or convection (heat
convector).
• Avoid rapid rewarming ,
monitor temperature every 30 minutes

90. Severe Hypothermia
• Give warm feeds immediately, if clinical condition
allows the child to take orally, else administer the
feeds through a nasogastric tube.
• Start maintenance IV fluids (prewarmed), if there is
feed intolerance/contraindication for nasogastric
feeding.
• Rehydrate using warm fluids immediately, when there
is a history of diarrhea or there is evidence of
dehydration.
• Start intravenous antibiotics
• Do not use hot water bottles due to danger of burning
fragile skin.

91. Dehydration
• Dx: assume that all children with watery
diarrhea or reduced urine output have some
dehydration.
• Only h/o fluid loss and very recent change in
appearance can be used.
• Treatment of dehydration is different in SAM
child from normally nourished child.

92. Dehydration
All star signs of dehydration are
unreliable in marasmic child.

93. Dehydration
• Rx: if conscious-
– No IV route unless in shock
– If Resomal is not available: -
Reduced osmolarity ORS is used ; add 15 ml of
potassium chloride to one litre ORS (15 ml contains
20 mmol/L of potassium)

94. Dehydration
How often to give ORS Amount to give
Every 30 minutes for first 2 hours 5 ml/kg weight
Alternate hours for up to 10 hours* 5-10 ml/kg *
*Then 10 mls/kg/hr each for the next 10-12 hrs on
alternate hrs, with F75 formula
*The exact amt depends on how much the child wants,
vol of stool loss and whether the child is vomiting.
If rehydration is still required at 10hrs, give starter F75
instead of Resomal, at the same times. Use same vol of
F75 as of Resomal

95. Signs to check
Every half hour for the first two hours, then hourly:
1. Respiratory rate
2. Pulse rate
3. Urine frequency
4. Stool or vomit frequency
5. Signs of hydration

96. Signs of over hydration
1. Increased respiratory rate and pulse. (Both must increase to
consider it a problem –increase of pulse by 15 & respiratory
rate by 5)
2. Jugular veins engorged
3. Puffiness of eye
4. Liver size increased
• Stop ORS if any of the above mentioned signs appear.

97. Dehydration
• A severely malnourished child is considered
in shock if s/he is:
• Lethargic or unconscious and
• Has cold hands
Plus either:
• Slow capillary refill (more than 3 seconds)
Or
• Weak or fast pulse

98. If in shock or severe dehydration
(unconscious)
• Weigh the child. Estimate the weight if child
cannot be weighed or weight not known
• Give oxygen
• Make sure child is warm
• Insert an IV line & draw blood for emergency
laboratory investigations
• Give IV 10% Glucose (5 ml/kg)

99. Dehydration
If in shock or severe dehydration (unconscious)
– cannot be rehydrated orally or by NGT, give IVF,
either RL & 5% dextose at 15 ml/kg in first hour.
– Reassess, if improving give 15 ml/kg in 2nd hr.
– If not improving- dx is septic shock

100. Septic shock treatment
• Give maintenance IV fluid (4 ml/kg/hr)
• Review antibiotic treatment
• Start dopamine
• Initiate re-feeding as soon as possible

101. Dehydration
• Monitoring:
• Expect RR, PR to fall
• Urine to be passed
• Return of tears, moist mouth, less sunken
eyes and frontanelle and improved skin tugor
• Wt of child
• Liver size
– Monitor every 30 mins for 2hrs then hrly for the
next 4-10 hrs

102. Dehydration
• Prevention of dehydration:
– CT breastfeeding
– Initiate re-feeding with starter F75
– Give 50-100mls Resomal per loose motion

103. Continuing diarrhoea
• Replacement fluids CT
• Stool m/c/s and treat accordingly. giardia;
metronidazole 7.5mg/kg TID x 7d
• Osmotic diarrhoea: Diarrhea worsens with
hyperosmolar F75 and ceases when sugar
content and osmolarity are reduced.Rx-lower
osmolar feeds

104. Electrolyte imbalance
• All severely malnourished children have
deficiencies in K+ & Mg2+ and excess sodium
• May take 2 weeks to correct
• Ideally should receive Mg, Zn, Cu and Se as
part of mineral mix – added to milk feed.
• Rx:
– Extra K+ 3- 4 mmol/kg daily
– Extra Mg2+ 0.4 – 0.6mmol/daily

105. Infection
• Signs like fever may be absent but still infection
present, assume all malnourished children have
an infection
• Rx:
– Start BS ab, measles vaccine if >6mths or
unimmunized , albendazole
– No complications: PO amoxicillin(45mg/kg/d BD) X5
days
– Complications(hypogly, hypotherm, lethargy): Im/iv
xpen (50000IU QID) or ampicillin(50mg/kg BD) X2
days, then oral amoxicillin( 30-40 mg/kg/day TID) X 5
days
– Plus Genta(7.5mg/kg OD) X7 days.

106. Infection
metronidazole 7.5mg/kg TID X7 days may be
added to the BS Abx .
• Rx for other infections as appropriate:
meningitis, pneumonia, dysentery, skin infxns,
malaria and TB)
– Parasitic worms: delay until rehab period. Give
ABZ STAT .

107. Micronutrients
• Give daily for at least two weeks
• Multivitamins supplement
– Folic acid- 5 mg on day 1 then 1 mg/day
– Zinc – 2mg/kg/day
– Copper - 0.3 mg/kg/day

108. Dermatitis of kwashiokor
• Due to zinc deficiency – give Zn.
• Soak/bathe areas in 0.01% potassium
permanganate sol. For 10min/day
• Apply barrier cream zinc and castor oil
ointments, petroleum jelly to raw areas, GV or
nystatin cream to skin sores
• Omit nappies/diapers, perineum can stay dry.

109. Micronutrients
Vitamin A-
• < 6 months- 50,000 iu
• 6 month-1yr-100,000 iu
• >1 yr- 200,000 iu)
on day 1, 2 and 14 – only if child has signs of def
eg corneal ulceration or Hx of measles
• Children more than twelve months but having
weight less than 8 kg should be given 100,000 IU
orally irrespective of age.

110. Micronutrients
• Once gaining weight and good appetite,
ferrous sulphate 3mg/kg/day. From the
second week
Severe Anaemia
• Transfuse: Hb < 4gldl,4-6g/dl in resp distress
• PCV – 10 ml/kg slowly for 3hrs + frusemide
1mg/kg iv at the start of transfusion

111. Initial feeding
Essential features
• Frequent small 2-3 hrly feeds of low osmolality ,low
lactose
• Oral/NGT feeds
• Never parenteral
• 100 kcal/kg/d
• Protein @ 1-1.5g/kg/d
• Liquid @ 130ml/kg/d (100 if with severe edema)
• If child is breastfeeding continue it but still give feeds
• Starter F75(75kcal/100ml and 0.9g protein/100ml)

112. Initial feeding
• Monitoring: amount of feed and left over,
vomiting ,diarrhea, daily body wt.
• If the child has poor appetite, encourage the
child to finish the feed.
• If eating 80% or less of the amount offered,
use a nasogastric tube. If in doubt, see feed
chart for intakes below which tube feeding
is needed

114. Catch up growth
• Signs that a child has reached this phase:
–return of appetite,
–edema gone and
–no episodes of hypoglycemia

115. Feeding for catch up growth
• Treatment:
– Gradual transition from starter to catch up
– Replace F75 with an equal amount of F100
(100kcal/100ml and 2.9g protein/100ml)
– On day 3 increase each successive feed by 10
ml till some remains uneaten at abt
200ml/kg/d
– After gradual transition give frequent feeds
unlimited amouts, 150-220kcal/kg/d, 4-6g of
protein/d

116. Feeding for catch up growth
– Start with small but regular meals and encourage
child to eat often 8 meals/day.
– Monitor for signs of heart failure due to fluid
overload.
– Assess progress: daily wt gain

117. Sensory stimulation
• Tender, loving care
• Structured play therapy for 15- 30 mins/d
• Physical activity as soon as the child is well enough.
• A cheerful, stimulating environment.
• Encourage mother’s involvement e.g. comforting,
feeding, bathing, play
• Provide suitable toys for the children.

118. Rehabilitation
• Appetite has returned
• Principles: encourage child to eat as much as
possible, breastfeeding, emotional care,
prepare diet for continued care
• Criteria for Discharge :, gaining weight
>5g/kg/d for 3consecutive days.
• Continue monitoring progress.

119. Discharge Criteria
• Child
1. Oedema has resolved
2. Achieved weight gain of >15% or gaining weight
>5g/kg/d for 3consecutive days.
3. Child is eating an adequate amount of nutritious
food that the mother can prepare at home
4. All infections and other medical complications
have been treated
5. Child is provided with micronutrients
6. Immunization is updated

120. Discharge Criteria
• Mother/caregiver
1. Knows how to prepare appropriate foods and to feed
the child
2. Knows how to give prescribed medications, vitamins,
folic acid and iron at home
3. Knows how to make appropriate toys and play with
the child
4. Knows how to give home treatment for diarrhoea,
fever and acute respiratory infections and how to
recognise the signs for which medical assistance must
be sought
5. Follow-up plan is discussed and understood

121. Weight Gain (g/kg/d) calculation
• Weight gain = {discharge weight in gms – minimum
weight in gms} * 1000/{minimum weight in kg x
number of days between date of minimum weight
and discharge day}
• The rate of weight gain for an individual is calculated as
the discharge weight minus the minimum weight
multiplied by 1000 to convert the weight gain to grams.
This is then divided by the admission weight to give
grams of weight gained per kilo body weight. Lastly,
this total weight gain is divided by the number of days
from the date of minimum weight to the date of
discharge, to give g/kg/d.

122. Weight Gain (g/kg/d) calculation
• e.g. Ramu a two year boy was admitted and
weighed 7.3 kg at admission and 8.4 kg at
discharge; Ramu stayed for 17 days at the
NRC.
• Weight gain for Ramu = (8.4 – 7.3) x 1000/7.3
x 17 = 8.8 gm/kg/day.
• Ramu’s weight gain is 9 gm/kg/day

123. Failure to respond criteria
• Failure to regain appetite-------on 4th day after
admission.
• Failure to start to lose oedema------on day 4th .
• Oedema still present---------on 10th day.
• Failure to gain at least 5 gm/kg/day for 3
successive days after feeding on catch up diet.

124. Follow up
• Planned and regular, nutrition clinic
• Risk of relapse greatest after discharge
• Should be seen after 2wks,1mth,3mths
• If a problem is identified more frequent visits
• Aft 6mths,do yearly visits till 3yrs of age.

125. Follow up
• Regular check-ups should be made at 2 weeks
in first month and then monthly thereafter
until weight for height reaches -1 SD or above.
If a problem is detected or suspected, visit/s
can be made earlier or more frequently until
the problem is resolved.

126. Follow up
• Before discharge, inform the ANM posted at the
nearest PHC or sub-centre in order to ensure
follow up.
• ASHAs and AWWs are an important link in
community based follow up of the child till full
recovery takesplace.
• All SAM children should be followed up by
health providers in the program till s/he reaches
weight-for-height of – 1SD.

127. PROGNOSIS
• Good if picked early before complications
have set in.
• Long-term effects include
• failure to thrive,
• behavioral and cognitive dysfunction,
• Small stature,
• Obstructed labour,
• Low birth wgt infants

128. Management of SAM children less
than 6 months of age
• Initial steps of management i.e. hypoglycemia,
hypothermia, dehydration, infection, septic shock are
same as for older children.
• Feed the infant with appropriate milk feeds for initial
recovery and metabolic stabilization.
• Wherever possible breastfeeding or expressed milk is
preferred in place of Starter diet. If the production of
breastmilk is insufficient initially, combine expressed
breast milk and non-cereal Starter diet initially.
• For nonbreastfed babies, give Starter diet feed
prepared without cereals

129. Management of SAM children less
than 6 months of age
• Provide support to re-establish breastfeeding as
soon as possible.
• Support and help to express breast milk if the
infant is too weak to suckle.
• Give supplementary milk feeds if breast milk is
not enough or if breastfeeding is not possible or
mother is HIV +ve and has opted for replacement
feeds.

130. Management of SAM children less
than 6 months of age
• Give good diet and micronutrient supplements to the
mother.
• In the rehabilitation phase, provide support to mother
to give frequent feeds and try to establish exclusive
breast feeding.
• In artificially fed without any prospects of breastfeeds,
the infant should be given diluted Catch-up diet.
[Catch-up diet diluted by one third extra water to
make volume 135 ml in place of 100ml].

131. Management of SAM children less
than 6 months of age
• On discharge the non-breastfed infants should be
given locally available animal milk with cup and
spoon
• The infant formulas are very expensive and
should only be advised if the parents can afford
this
• Discharge the infant from the facility when
gaining weight for 5 days and has no medical
complications.

132. Supplementary Suckling Technique
(SST)
Relactation through Supplementary Suckling
Technique –
• Supplementary Suckling Technique (SST) is a
technique which can be used as a strategy to
initiate relactation in mothers who have
developed lactation failure

133. Supplementary Suckling Technique
(SST)

134. THANK YOU