This document discusses various approaches to nutritional rehabilitation for malnutrition, including hospital-based, centre-based, and community-based rehabilitation. It describes diets used in rehabilitation such as milk-based diets and ready-to-use therapeutic foods. It also discusses criteria for transferring patients to rehabilitation, staffing of rehabilitation centres, community nutrition programs, and developmental stimulation techniques.

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 d
oes not get the right amount of the vitamins, minerals
&other nutrients it needs to maintain healthy tissues an
d 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
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

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:
1) Early diagnosis & Treatment
2) Prevent recurrence in treated child
3) 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 Dece
mber 18, 2003. http://www.emedicine.com/ped/topic1
360.htm.
• Recent Advances in Communinity Medicine-
Suryakantha
• Text Book of Preventive social Medicine- Park 23rd
Edition