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Press Information Bureau

Government of India

Ministry of Women and Child Development04-May-2012 18:08 IST

Nutritional Rehabilitation Centres

Nutrition Rehabilitation Centres (NRCs) have been set up in various states to address severe

under-nutrition and underlying complications. The National Rural Health Mission (NRHM),Ministry of Health and Family Welfare facilitates the states in setting up the NRCs.

The number of NRCs, State-wise is as follows-

S. No. State No. of NRCs

1 Bihar 34

2 Chhattisgarh 40

3 Himachal Pradesh 0

4 Jammu & Kashmir 0

5 Jharkhand 53

6 Madhya Pradesh 262

7 Orissa 5

8 Rajasthan 140

9 Uttar Pradesh 19

10 Uttarkhand 0

11 Arunachal Pradesh 0

12 Assam 3

13 Manipur 0

14 Meghalaya 0

15 Mizoram 0



16 Nagaland 0

17 Sikkim 0

18 Tripura 019 Andhra Pradesh 0

20 Goa 0

21 Gujarat 71

22 Haryana 0

23 Karnataka 15

24 Kerala 0

25 Maharashtra 6

26 Punjab 0

27 Tamilnadu 0

28 West Bengal 6

29 Andaman & Nicobar 0

30 Chandigarh 0

31 Dadra & Nagar Haveli 0

32 Daman & Diu 0

33 Delhi 3

34 Lakshadweep 0

35 Puducherry 0

Total 657

The Prime Minister’s National Council for India’s Nutrition Challenges provides policydirections, reviews, and coordinates amongst various programmes. There are various

programmes for provision of food/supplementary nutrition.

Supplementary nutrition as a gap filling measure is provided to children below six years of age,

pregnant and nursing mothers as one of the services under the Integrated Child Development



Services Scheme (ICDS). Under Mid-Day-Meal food is provided to children 6-14 years of age,

for school going children from class I to class VIII. Under Integrated Child Protection Schemes

(ICPS) and creche Scheme also support is given to the eligible children for food as per norms of the Scheme. The recently introduced Rajiv Gandhi Schemes for Empowerment of Adolescent

Girls (RGSEAG), namely SABLA provides a package of services including health and nutrition

to adolescent girls in the age group of 11-14 years for out of school girls and 15-18 years for allgirls for nutrition in 200 districts as a pilot. Moreover, the Indira Gandhi Matritva Sahyog

Yojana (IGMSY) provides cash assistance as an enabling environment for improved health and

nutrition to pregnant and lactating mothers and support for providing early and exclusive breastfeeding for the first six months of life. It is being implemented on pilot basis in 52 districts.

There is availability of essential food items at subsidized cost through Targeted Public

Distribution System, Antodaya Anna Yojna for general public. Furthermore, the Government has

also introduced the Food Security Bill in the Lok Sabha.

This was stated by the Minister for Women and Child Development, Smt. Krishna Tirath, in awritten reply to a question in the Lok Sabha today.

****

MV

Introduction

Socioeconomic Status (SES) is an important determinant of the standard of living and healthstatus as it influences the incidence and prevalence of various health conditions. Socioeconomic

status also influences social security in terms of the accessibility, affordability, acceptability andactual utilization of various health facilities.

The need for developing a uniform system of socioeconomic classification of the population

universally based on the income with scientific basis and should applied with ease and simplicityin each sector or strata wise of population.

There have been several attempts to develop different scales to measure socioeconomic status but Prasad's classification (1961) [1] based on the per capita monthly income and later modified in

1968 [2] and 1970, [3] has been extensively used in the Indian scenario and has been quite effective

in performing the t task under discussion. But with the passage of time and due to theinflationary trends in the economy, the original income limits set in these classifications have

become substantially low and impractical. Realizing this need, Kumar [4] has updated the

classification linked with the All India Consumer Price Index (AICPI) which has also becomeimpractical today and has lower validity due to great variations in the Consumer Price Index.

By 1993-1994 however, the inflation rate was governed by the All India Whole Price Index

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series, [5] creating an urgent need to link Prasad's classification (1961) with the All India Whole

Price Index whereas Prasad's (1961) classification has taken for a basis of modification in terms

of latest scenario of cost of living index (COLI). In order to solve this problem, a hypotheticalvalue (0.53) [6] has been developed in relation to the base year of 1993-1994 when the new series

of the All India Wholesale Price Index started. [5],[7]

The hypothetical value was calculated based on the concept of the cost-of-living index (COLI),

which pertains to the WPI in India. As the COLI is not directly observable, the WPI employs a

number of formulae that offer approximations to the measurement objectives. WPI uses theLaspeyres formula to average the price changes due to inflation across different categories of

items, because COLI for the each current month is based on the cost of this month's market

prices for the items used by the community may be changed due to inflation in wholesale price,

of achieving the standard of living actually attained in the base period. [8],[9]

The ratio of this hypothetical cost to the actual cost of the base period is the lowest expenditure

level necessary at this month's price to achieve the base period's living standard. This framework

of WPI and the inflation rate from the base period has guided and will continue to guideoperational decisions about the construction of the index. [8],[9]

It is a simple method of multiplying the income limits of classification with a multiplication

factor and rounding off the values to the nearest rupee. Multiplying the AIWPI at the time of

study by the hypothetical value could help to derive the multiplication factor.

Therefore, the multiplication factor = Value of AIWPI [10] x 0.53

The next step is to multiply Prasad's income limits by the multiplication factor. There is onemore class-'Below Poverty Line' (BPL) included by the author because this concept of Below

Poverty Line was not started in 1961.

Income limits thus obtained, are far more practical and realistic. For example, to compute a

social classification for December 2004, the multiplication factor will be = 189.2 [10] x 0.53 =

100.27 or 100.

The proposed classification for this period is given in [Table - 1].

As such the value of the AIWPI has not varied according to the geographical area or work forcesand urban or rural conditions do not influence the classification. Hence, the value of the AIWPI

can be used safely and are regularly published in various weekly fortnightly financial

newspapers and magazines.

References

1. Prasad BG. Social Classification of Indian families. J Indian Med Assoc 1961;37:250-1.

2. Prasad BG. Social Classification of Indian families. J Indian Med Assoc 1968;51:365-6.






















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3. Prasad BG. Changes proposed in Social classification of Indian families. J Indian Med

Assoc 1970;55:198-9.4. Kumar P. Social classification-need for constant updating. Indian J Community Med

1993;18:2.

5. Hindu Business Line. 2004; 12th

March.6. Economic Advisor, Department of Industrial Policy and promotion, Govt. of India. 2001.

7. Kumar R, Mehndiratta D. Hindu Business Line. 2004; 11 th Oct.8. A conceptual framework for the revised price index. Proceedings of the business and

economic statistics section. American Statistical Association: 1974. p. 46-72.

9. Measurement issues in the price index. Statistical Journal of the United Nations, ECE 15,

ISO Press: 1998. p. 1-36.10. Hindu Business Line 2005; 15 th Jan.

Tables

[Table - 1]

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Backgound: The state of Madhya Pradesh has 1.3 million severely malnourished children.

Nutrition rehabilitation centers (NRCs) were started in the state to control severe malnutritionand decrease the prevalence of severe malnourished children to less than 1% among children

aged 1-5 years. Materials and Methods: The present study was conducted from November

2008 to October 2009; 100 children admitted to seven different NRCs in Indore and Ujjaindivisions of Madhya Pradesh were observed during their stay at NRCs and the follow-up period

to analyze the effect of interventional measures on select anthropometric indicators. Mothers of

the children were interviewed on health issues and therapeutic feeding practices at the NRCsusing a predesigned and pretested interview schedule. Results: The study group consisted of 48

boys and 52 girls; 60% were between 13 and 36 months of age. 93 children were analyzed for

anthropometric indicators following a dropout rate of 7%. A statistically significant difference

was obtained between the weight of children at admission and discharge (t=14.552, P<0.001);

difference of mid upper arm circumference (MUAC) at admission and discharge was statisticallysignificant (t=9.548, P<0.001). The average weight gain during the stay at the centers was 9.25 ±

5.89 g/kg/day. Though the number of severe malnourished children decreased from 85 to 43following the stay at NRCs (χ 2 = 44.195, P<0.001); 48.78% of the children lost weight within 15

days of discharge from the NRCs. Dropout rates of 9.89%, 23.07%, 42.65%, and 61.76% for the

study group were obtained during the follow-up period of 6 months for the four follow-up visitsconducted 15 days, 1, 3, and 6 months after discharge. The mothers of the children lacked

adequate information on health issues and composition and preparation of therapeutic diets at the

centers. Conclusion: The NRCs were effective in improving the condition of admitted children,

but the effects were not sustained following discharge due to high drop-out rate and lack of adequate parental awareness. There is an urgent need to link these centers with community-based

models for follow-up and improve health education measures to maintain the gains achieved.

Keywords: Nutrition rehabilitation centers, severe acute malnutrition, therapeutic feeds

How to cite this article:

Taneja G, Dixit S, Khatri A K, Yesikar V, Raghunath D, Chourasiya S. A study to evaluate the

effect of nutritional intervention measures on admitted children in selected nutrition rehabilitationcenters of Indore and Ujjain divisions of the state of Madhya Pradesh (India). Indian J

Community Med 2012;37:107-15

How to cite this URL:

Taneja G, Dixit S, Khatri A K, Yesikar V, Raghunath D, Chourasiya S. A study to evaluate the

effect of nutritional intervention measures on admitted children in selected nutrition rehabilitationcenters of Indore and Ujjain divisions of the state of Madhya Pradesh (India). Indian J

Community Med [serial online] 2012 [cited 2013 Jul 16];37:107-15. Available

from: http://www.ijcm.org.in/text.asp?2012/37/2/107/96096

http://www.ijcm.org.in/text.asp?2012/37/2/107/96096




Introduction

The state of Madhya Pradesh has the largest number of malnourished children in India; 6 million

children under five are malnourished including 1 million moderately malnourished and 1.3million severe malnourished children. [1] To combat this menace, the Government of Madhya

Pradesh initiated the bal sanjeevni drive in the year 2001 with support from United Nations

Children Fund (UNICEF) aimed at identifying and treating malnourished children. To prevent

deaths among severe malnourished children identified under the drive, the Government further started the Nutrition rehabilitation centers (NRCs) under the Bal Shakti Yojna with support from

UNICEF. The objectives of the programme are to control malnutrition among the children aged

1-5 years in the state and to bring down the percent of severe malnourished children to less than1%. [2]

The first of such centers was set up in 2007 and in a short span of 2 years the number of suchcenters has increased to 175. The inputs being put in the NRCs have to be adequately analyzed to

evaluate whether the desired objectives are being fulfilled. The present work tries to analyze the

effect of the NRCs in improving the health and nutritional status of severe malnourished children

admitted at the centers by studying the effect of the interventional measures on the admittedchildren and the effect of health education measures undertaken at the centers.

Objectives

1. Evaluate the effect of nutritional interventional measures undertaken at NRCs inimproving the nutritional status of admitted children through review of select

anthropometric indicators at the time of admission and discharge and during their stay atthe centers.

2. Follow-up the study group after discharge to check the compliance level among beneficiaries to recommended follow-up visits and assess the effect on nutritional status

through review of select anthropometric indicators following discharge.

3. Ascertain the awareness and knowledge amongst mothers of the admitted childrenregarding the practices followed at NRCs during their stay at the centers.

Functioning of NRCs

At the centers nutritional and medical intervention (appropriate antibiotics, deworming tablets,iron supplementation, and micronutrients) is provided to the children. Severe malnourished

children are recognized in their respective localities by the Anganwadi Workers (AWWs) and

brought to the centers by the AWWs. An incentive of Rs 100 is provided to the AWW for counseling of the mother to stay at NRC for 14 days at the time of admission. At NRCs, the

children are admitted and nutritionally rehabilitated for a minimum period of 14 days [2] using

therapeutic feeding diets (F-75, F-100 and lactose free diet) prepared using locally availablefoodstuff. If needed the children are medically rehabilitated as per the Indian Academy of

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Pediatrics (IAP) protocol for severe malnourished children. [3] Supervised feeding of therapeutic

diets is done by the NRC staff (Feeding Demonstrators and Cooks) and medical intervention is

provided by the doctor in charge and the nurses at the centers. Though designated for severemalnourished children, moderate and mild malnourished children are also admitted if there are

associated medical complications. Anthropometric indicators [weight, height, and mid upper arm

circumference (MUAC] are monitored to observe the effect of interventional measures on thehealth status of the admitted children. Anthropometric assessment of the children is done by the

NRC staff using standard validated measurement techniques. Weight of the children is taken

using electronic weighing scales (Seca: GMBH and company; model number 3341321008),length using length boards (Seca: GMBH and company; model number 2101821009), and

MUAC measured by an MUAC tape designed by UNICEF and based on Shakir's tape for

measuring MUAC.

The mothers of the children are made to stay at the centers where counseling sessions focusing

on health and nutrition aspects are conducted for them. The mothers are also provided hands on

training on composition and preparation of the therapeutic diets and given compensation for

daily wage loss as per guidelines during their stay at the NRCs.

[4]

A sum of Rs. 90 per child is allocated/day during their stay at the centers. Out of this, Rs. 25 is to be spent for the food of the child and Rs. 65 to be handed over to the mother compensating for

her wage loss. [4]

The children are discharged after a minimum period of 14 days, provided the child does not

show any obvious signs of infection or edema, has received the stipulated amount of

micronutrients, is gaining at least 8-10 g/ kg/ day, and the mother has improved understanding of

correct feeding practices. The children are again brought to the center by the AWWs on thedesignated follow-up dates at 15 days, 1 month, 3 months, and 6 months following discharge

from the NRCs wherein the AWWs are paid an incentive of Rs. 100 for bringing the child for

each follow-up visit. The mother also receives a sum of Rs. 65 to compensate for her daily wageloss. The same anthropometric measurements are taken on the follow-up visit and the child

treated for medical conditions; the child is also readmitted if needed.

Materials and Methods

The present study was conducted in seven NRCs located across six districts in Indore and Ujjaindivisions of the state of Madhya Pradesh from November 2008 to October 2009 [Figure 1]. At

the time of initiation of the study, Indore and Ujjain divisions had 48 functional and 7

nonfunctional NRCs. 15% of the operational NRCs were randomly selected for the study. Owingto time constraints and the 6-month follow-up period involved, the study was conducted on a

predecided sample size of 100 children aged between 0 and 60 months admitted to the selected

NRCs. The study design was prospective, wherein 100 children were recruited from the seven NRCs and were then followed up for the period of 6 months (incorporating four follow-up visits

during this period as stated earlier) to assess the nutritional status during the period of initial stay

and the entire follow-up period using available records of anthropometric indicators of the

admitted children recruited in the study at the NRCs. Initial recruitment of the children was done




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during the months of December 2008-January 2009 and the follow-up period extended up to July

2009. Children were recruited from the different NRCs depending upon the bed capacity and the

patient turnover rate at the centers during the study period [Table 1]. The seven selected NRCswere visited by the investigators at intervals of 15 days during the months of December 2008-

January 2009 and all children admitted at that particular day of the visit were included in the

study. Thus, more children were recruited from centers with higher bed capacity and higher admission rates. Once the figure of 100 was achieved the process of recruitment was stopped.

Weight at the time of admission and discharge and daily weights were recorded from the NRCregisters; average weight gain was calculated to see if it was in accordance with the available

guidelines. [5] Appropriate statistical tests were applied to ascertain any significant difference

between the mean weights at discharge and the mean weight at admission for the study group. In

addition, the MUAC and grades of malnutrition at admission and discharge were also recordedand the average duration of stay at the centers studied to establish any difference amongst the

different age groups.

The children included in the study were followed up for 6 months to observe the complianceduring the follow-up period; follow-up records at the centers were analyzed to calculate the

number of subjects with loss of weight at each follow-up visit, and the mean loss of weightcompared to the previous follow-up visit.

A predesigned and pretested semistructured interview schedule was used to interview themothers of the admitted children on awareness regarding government programmes focusing on

nutrition, basic concepts of nutrition, etiologies of malnutrition, and the impact of hands on

training provided at the centers, which focused on the composition and preparation of therapeutic

diets at the centers.

Table 1: Selected nutrition rehabilitation centers and corresponding

study subjects

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Figure 1: Map showing the selected study districts in the state of

Madhya Pradesh. The study districts: Dewas, Dhar, Indore, Khandwa,Khargone and Ujjain

Click here to view

The data were entered into Microsoft excel spreadsheet and analyzed using SPSS version 17.

Statistical tests such as t-test, χ 2 test, and ANOVA were applied wherever needed.

Results

Sociodemographic profile of participants

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The study group included 48 boys and 52 girls. 40% of the children were in the age group of 13-

24 months (19 boys and 21 girls) and 20% in the age group of 25-36 months (12 boys and 8girls). The mean age duration for the entire group was 23.95 ± 13.68 months; for boys 26.29 ±

13.18 months and for girls 21.75 ± 13.94 months. 41% of the study population belonged to the

scheduled caste (SC) group and 25% each to the other backward classes (OBC) and scheduledtribes (ST). 63% of the parents of the admitted children were illiterate, 15% had received

education up to primary school, and 0.5% of the parents were graduates. 58% of the parents of

the admitted children were daily wage laborers, 14% were farmers, while 40% of the motherswere housewives. Families of 99% of the study subjects fell in Grade VI (below poverty line)

and Grade V (poor) socioeconomic class based on Agarwal's modification of the original

Prasad's classification. [6]

Effect on selected anthropometric Indicators of the admitted children during stay at the

NRCs

Analysis of the admitted children based on weight

A total of 93 children were included in the analysis: 45 (48.39%) boys and 48 (51.61%) girlswere analyzed for effect of nutritional interventional measures on anthropometric indicators as 6

children (3 boys and 3 girls) did not stay at the centers for the entire duration of 14 days and 1

girl was referred to another health care setting. 37.63% were in the age group of 13-24 monthsand 21.51% in the age group of 25-36 months. The overall mean weight of admission for these

children was 6.51 ± 2.04 kg; for boys 6.89 ± 1.96 kg and for girls 6.15 ± 2.08 kg. The mean

weight at discharge for the study group was 7.16 ± 2.13 kg; for boys 7.49 ± 2.08 kg and for girls

6.86 ± 2.16 kg. A statistically significant difference was observed between the mean weight atdischarge and the mean weight at admission for the study group (t=14.552, P <0.001) and for

boys (t=9.904, P <0.001) and girls (t=10.475, P <0.001) separately [Table 2].

Table 2: Mean weights at admission and discharge (n=93)

Click here to view

The average weight gain for the study group during their stay at the centers was 9.25 ± 5.89

g/kg/day; for boys the average weight gain being 8.29 ± 5.20 g/kg/day and for girls 10.14 ± 6.39

g/kg/day. An average weight gain of at least 8 g/kg/day is considered to be adequate for a child

during stay at the residential therapeutic centers. [5] 50 children (20 boys and 30 girls) had anaverage weight gain of >8 g/kg/day, while 43 had a weight gain of <8 g/kg/day [Table 3].

Table 3: Age wise distribution for the average weight gained (n=93)

Click here to view

At the time of admission, 85 (91.4%) children were severely malnourished (Grades III and IV),

while 08 (8.6%) children suffered from moderate or mild malnutrition (Grades I and II). [7] 43


















(46.24%) children were still severely malnourished (Grades III and IV), while 50 (53.76%)

children were suffering from moderate or mild malnutrition (Grades I and II) at discharge.

McNemar's chi-square test was applied and the difference between children severelymalnourished at the time of discharge as compared to admission was observed to be statistically

significant (χ 2 =44.195, P <0.001) [Table 4].

Table 4: Severely malnourished children at the time of admission anddischarge (n=93)

Click here to view

Analysis of the admitted children based on MUAC

MUAC data were analyzed for 75 children. Six children were not included because of default,

one child had been referred to another health care facility and MUAC was not measured in

children less than 6 months (seven in number). Further 11 children from one particular study

center were not included in the analysis as the center staff did not measure MUAC at discharge.

The mean MUAC at admission was 11.32 ± 1.18 cm and at discharge it was 11.94 ± 1.38 cm.

The difference was observed to be statistically significant (t=9.548, P <0.001). The mean MUACfor the boys at admission was 11.33 ± 0.98 cm and at discharge it was 11.87 ± 1.01 cm, which

was statistically significant (t=6.876, P <0.001). Similarly for girls the mean MUAC at admission

was 11.31 ± 1.38 cm, at discharge it was 12.01 ± 1.33 cm, the observed difference beingstatistically significant (t=6.723, P <0.001).

Duration of stay at the NRCs

The average duration of stay at the NRCs was 13.81 ± 2.73 days, for boys it was 14.73 ± 1.98days and for girls it was 14.13 ± 1.20 days. 86 (92.47%) of the children in the study group had

stayed at the NRC at the centers for at least 14 days. No statistically significant difference wasobserved among the different age groups with respect to duration of stay at the centers (F=1.208,

P=0.312).

Analysis of follow-up data

From the 93 children for which initial anthropometric data were analyzed, 2 children were

excluded because of readmission on the first follow-up visit; thus, a total of 91 children wereincluded for the follow-up analysis. Since there was no uniformity amongst the different study

centers regarding the recording format for anthropometric indicators during follow-ups, onlyweight of the children at the various follow-ups was included in the final analysis. For the thirdand fourth follow-ups, 9 children from one center were excluded as the center had shifted over to

the new follow-up pattern of 2 months duration. [8] One NRC closed down during the study

duration; so the 13 children admitted to this particular center did not receive the third and fourthfollow-ups and hence were excluded from the final analysis for the last two follow-ups; a child

was excluded as the child was transferred to another hospital setting. Thus, a total of 68 children

were analyzed for the last two follow-ups [Table 5].











Table 5: Age and sex wise distribution of children at the different

follow-ups

Click here to view

Of a total of 91 children available for analysis for the first two follow-up visits, 82 childrenreported for the first follow-up visit and 70 for the second. Similarly of the 68 children available

for analysis for the third and fourth follow-up visits, 39 children reported for the third and 26

children for the fourth visit. Dropout rates of 9.89%, 23.07%, 42.65%, and 61.76% wereobtained for the four follow-up visits conducted 15 days, 1 month, 3 months, and 6 months from

the day of discharge as per recommended guidelines. This dropout rate at each follow-up visit

was found to be statistically significant (χ 2 =61.106, P <0.001). If calculated from the baselinedata of 100 children, the dropout rates would be 18%, 30%, 61%, and 74% for the four follow-

ups.

Though there was an increase in mean weight of the children who returned for the follow-upvisits, it was offset to a certain extent by the loss of weight experienced by some children in the

study group. The loss of weight was maximum immediately, following the period of discharge as

48.78%, had lost weight on the first follow-up visit, a progressive increase in proportion of children gaining weight was noted in children who turned up for all the four visits [Table 6].

[Table 7] outlines the mean weight at each follow-up visit and also provides details on the

proportion of the children (mean weight loss) who had lost weight during each follow-up visit ascompared to the weight during the previous follow-up visit.

Table 6: Proportion of children with weight gain and weight loss at each

follow-up visit

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Table 7: Details of follow-up visits with mean weight and proportion of

children with weight loss at each follow-up visit

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Knowledge and awareness among mothers of beneficiaries at the centers

Awareness regarding community programmes on nutrition and concepts of nutrition

Though 36% of the mothers were aware of the existence of NRCs, most of them were ignorant

about the actual name of the center. 3% had heard about the Bal Shakti Programme, 7% had

some knowledge about the various types of nutrients and their importance, 2% correctly knew

about the preparation and use of Oral Rehydration Solution (ORS), while 23% had inadequateknowledge about its use. 6% of the mothers had proper knowledge about the clinical symptoms

of vitamin A deficiency.














Awareness regarding etiology of malnutrition

92% of the mothers had no knowledge about the etiologies of malnutrition. Inadequate diet and poor quality of food were considered to be the main reasons responsible for malnutrition by 4%

mothers each with repeated infections and lack of immunization being the other contributing

factors.

Knowledge regarding therapeutic feeding practices at NRCs

56% of the mothers said that they had been taught the preparation of the therapeutic diets at the

centers. Though majority of mothers had proper information regarding the time interval of feeds

at the NRCs, just 4% had correct knowledge (the correct constituents and correct method of

preparation) about F-75 diet and 2% about F-100. None of the mothers had any knowledge aboutthe lactose-free diets [Table 8].

Table 8: Knowledge regarding therapeutic feeding practices at NRCs

(n=100)

Click here to view

Mothers also raised concerns about the reimbursement provided at the NRCs, the unavailability

of daily diets for them at the centers, and the absence of provision of food to the accompanying

siblings of the admitted child.

Discussion

The study findings show that a major proportion of the admitted children belonged to themarginalized population groups. The findings are in accordance with that of NFHS-III, which

states that children belonging to the SC, ST, and OBC and that those with illiterate mothers have

the highest rates of malnutrition. [9]

An initial dropout rate of 7% was noted in the present study. In a study in Burkina Faso among

1322 children dropout rates of 8.5% were noted. [10]

Weight has been taken as the main anthropometric measure as an improvement in weight of

severe malnourished children has the most significant effect in reducing the mortality among

them. The study findings reveal a statistically significant difference between the mean weight atdischarge and the mean weight at admission for the entire study group (t=14.552, P <0.001) and

for boys (t=9.904, P <0.001) and girls separately (t=10.745, P <0.001). Colecraft et al . in a study

at four day care NRCs also reported a significant increase in weight for age for the admittedchildren. [11]

The average weight gain for the entire study group was 9.25 ± 5.89 g/kg/day, which is

comparable to results observed by Savadago et al . in a study at Burkina Faso which reported an














average weight gain of 10.18 ± 7.05 g/kg/day; [10] findings reported by a set of studies in

Bangladesh comparing inpatient, day care and home-based treatment for severe malnourished

children observed an average weight gain of 11 g/kg/day for the inpatient group. [12],[13],[14]

A recovery rate of 53.76% (children with average weight gain of more than 8 g/kg/day) was

observed amongst the study group; recovery rate of 52.7% using the above internationalstandards was obtained by Gaboulaud et al. in a study comparing therapeutic feeding centers

(TFC) care, TFC plus home-based care, and only home-based care amongst 660 children in the

TFC group. [15]

The difference between MUAC at discharge and at admission was found to be statistically

significant for the entire study group (t=9.548, P <0.001), for boys (t=6.876, P <0.001) and girls

(t=6.723, P <0.001). MUAC is very easy to measure and hence should be used appropriately and judiciously for monitoring children at the NRCs.

Though the number of children suffering from severe malnutrition decreased from 91.4% to

46.24%, the difference being statistically significant (χ

2

=44.195, P <0.001), 43 children were stillin the high risk group at the time of discharge. Appropriate criteria must be designed which

specifically adopt a target weight for each child with the child being discharged once the targetweight is achieved provided the child has been appropriately rehabilitated with nutritional and

medical measures.

The median duration of stay at the centers was 14 days, which is much less than earlier

programmes for children with severe Protein Energy Malnutrition (range from 6 weeks to 8

months). [16],[17],[18] The short duration of stay not only decreases costs but also minimizes the

absence of mothers from their homes which has important implications at the society level.Effectively, the duration of stay needs to be balanced between the chances of cross exposure to

infection and the readiness of the mothers to effectively manage their children at home.

The study findings reveal increasing drop outs rates with each successive follow-up. A

comprehensive review by Ashworth et al. comparing inpatient, outpatient, and home-based care

and home-based care alone in Bangladesh revealed a dropout rate of 23% for the inpatient groupover a 12 month period, the highest in the three groups. [12],[13],[14] The low compliance during

follow-up visits limits the overall success rate of the programme. Effective measures are needed

to improve the compliance rates for follow-up visits. Community mobilization needs to be done

and the community should be made aware of the functioning of the centers. Creating a network of outreach workers from the NRCs or selecting volunteers on the lines of the Revised National

Tuberculosis Control Programme (DOTS provider) from different localities who can monitor the

follow-up dates of the discharged children and help the AWWs in decreasing the number of dropouts.

The mothers attending the centers had limited knowledge regarding the basic concepts of nutrition, the Government Health Programmes on nutrition and the composition and preparation

of therapeutic feeds at the centers. Mothers are specifically kept at the centers so that they can so

that they can be integrated into the effective care of the children and are taught the preparation of

the therapeutic diets from locally available material. Surprisingly, this fact is often ignored and at


































the centers and much attention is paid to the improvement in nutritional status of the children,

which is essentially considered to be the criteria of the success of the programme. Beghin in his

critical assessment of 21 NRCs across 6 Latin American countries found nutrition education to be lacking at most of the centers he visited. [19]

44% of the mothers said that they had not been taught the preparation of the therapeutic diets.This is clearly reflected in the fact that 48.78% of the children had lost weight within 15 days of

discharge. The period immediately following discharge is most important as mothers find it

difficult to comply with the intervention strategies taught at the center, which indirectly lowersthe compliance to follow-up visits. Educating the AWWs on the feeds prepared at the centers can

help the mothers when they go back to their homes and help maintain the growth achieved at the

centers. The loss of children during follow-up visits can only be reduced to a certain extent and

hence nutrition education measures must be stressed upon during the initial stay at the centers.Counselling sessions focusing on the general health education measures should be undertaken to

prevent malnutrition and mothers should be mandatorily made to prepare the therapeutic diets at

the centers.

Most of the mothers in the study belonged to poor socioeconomic background. This limits the

accessibility to even cheap locally available food, as outlined by earlier studies, [11] hence providing some sort of assistance in the form of adequate ration to the mothers used in preparing

of the therapeutic feeds lasting till the next follow-up can be initiated, alternate arrangements of

providing that ration to Anganwadi Centers of the areas can be done from where the feeds can bedistributed to the mothers of the affected children. Often in our society mothers do not enjoy the

rights to decide what to feed in the family, hence involving fathers and other caregivers of the

family in the programme should be undertaken.

An important area of debate is the amount of reimbursement paid to the mothers during their stay

at the centers. The present amount of Rs. 65 per day is much less as compared to the minimum

daily wages presently paid through the labour schemes of the Government of India. In addition,mothers at some centers had to be provided food from sources other than the hospital mess. The

amount spent on food was deducted from the compensation provided for the daily wage loss;

also lack of provision of food to the accompanying children was an important issue raised by themothers of the admitted children. These factors can adversely affect the compliance of mothers

at the centers. Providing food separately to the mothers and accompanying children should be

undertaken so as to prevent food sharing between the mothers and the accompanying siblings. If

food is to be made available from outside sources the amount incurred should not be deductedfrom the compensation for the daily wage loss.

Available literature also points toward the inherent weaknesses in the set up: Limited inpatientcapacity and lack of enough skilled staff to treat the large number of children needing care. [20],[21]

The state of Madhya Pradesh has at present 1.3 million severe malnourished children [1] with 175

operational NRCs. Available guidelines state establishing 20 bedded NRCs at district level and10 at block level. [8] Assuming all the centers to be 20 bedded the number of children treated

every month works out to be 40 (20 children for 14 days each). Thus in one year the number of

children who can be treated at the centers comes as 84,000. To treat the entire 1.3 million

children it would take approximately 15.5 years, assuming no failure or readmission rates. If the




















1 million moderately malnourished children are also included in the purview, it would take

another 12 years to achieve the objective.

Thus NRCs cannot be the only tool to combat malnutrition; the study results show that the NRCs

have had a positive impact on the selected anthropometric indicators of severe malnourished

children but lag behind in the educational aspect and ensuring proper follow-up visits. Linking of NRCs with the community-based Core Model of Management of severe malnourished children

needs to be put into place as soon as possible. [22],[23] This model is the current protocol envisaged

by the World Health Organization and provides a framework for an integrated Public Healthresponse to curb malnutrition, treating most patients with severe malnutrition at home with

inpatient care being reserved for those with acute complications, thereby minimizing the cost to

families and maximizing access to treatment. [24]

However, establishment of such a model of treatment would require large resource mobilization

both in terms of money and human resource with special emphasis on training aspects along with

the motivational issues involved. A delicate balance needs to be achieved between both the

modalities of treatment, and until the community-based model is put in place NRCs will continueto act as a major tool to adequately and effectively address the glaring issue of malnutrition in

the state of Madhya Pradesh and the country.

The study is prone to observer bias as it is based on secondary data. Selection bias was

introduced in the study because of the purposive sampling used to recruit the study children. Thestudy has its limitations in that it was conducted in a limited group of subjects and was restricted

to a few districts of the state. Studies with bigger sample size selected from NRCs across the

state of Madhya Pradesh will give a more composite view of the actual effect of the NRCs in

checking the prevalence of malnutrition in the state.

Acknowledgement

The authors are thankful to Dr. Satish Saroshe (Post Graduate Student), Department of

Community Medicine forhis help in the completion of the study.

References

1. Chaudhury M. Madhya Pradesh: Epicentre of hunger. NDTV. Available from:

http://www.ndtv.com/news/india/madhya_pradesh epicentre_of_hunger.php. [Last accessed

on 2009 Aug 20].

2. Bal Shakti Yojna. Government of Madhya Pradesh, Innovative Schemes and Programme

Interventions under NRHM, Department of Public Health and Family Welfare, Bhopal.Available from: http://www.mp.gov. in/health/nrhm/Innovative-nrhm.pdf. [Last accessed on

2009 Aug 20].

3. Bhatnagar S, Lodha R, Choudhury P, Sachdev HP, Shah N, Narayan S, et al . IAP guidelines








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2006 on hospital based management of severely malnourished children (adapted from the

WHO Guidelines). Indian Pediatr 2007;44:443-61.

4. Bal Shakti. Guidelines for Management of severely Malnourished Children at Nutrition

Rehabilitation Centers. Government of Madhya Pradesh. New York, USA: UNICEF;

2008.

5. Golden M, Grellety Y. Guidelines for the Integrated Management of the severely

malnourished. (Draft copy) 2008.

6. Agarwal A. Social classification: The need to update in the present scenario. Indian J

Community Med 2008;33:50-1.

[PUBMED]7. Park K. Textbook of Preventive and Social Medicine. Preventive Medicine in Obstetrics,

Pediatrics and Geriatrics: Growth Charts used in India. 20 th ed. Chapter; Jabalpur:

Banarsidas Bhanot; c2009. p. 470-1.

8. Secretariat health Services; Government of Madhya Pradesh: Guidelines to improve

services in functioning of Nutrition Rehabilitation Centers. No R.C.H/09/5734; 30.06.09.

9. International Institute of Population Sciences. National Family Health Survey -3. Mumbai:

IIPS, ORC Macro; 2005.

10. Savadogo L, Zoetaba I, Donnen P, Hennart P, Sondo BK, Dramaix M. Management of

severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso. Rev

Epidemiol Sante Publique 2007;55:265-74.

11. Colecraft EK, Marquis GS, Bartolucci AA, Pulley L, Owusu WB, Maetz HM. Alongitudinal assessment of the diet and growth of malnourished children participating innutrition rehabilitation centres in Accra, Ghana. Public Health Nutr 2004;7:487-94.

12. Khanum S, Ashworth A, Huttly SR. Controlled trial of three approaches to the treatment of severe malnutrition. Lancet 1994;344:1728-32.

13. Ashworth A, Khanum S. Cost-effective treatment for severely malnourished children: What

is the best approach? Health Policy Plan 1997;12:115-21.

14. Khanum S, Ashworth A, Huttly SR. Growth, morbidity, and mortality of children in Dhaka

after treatment for severe malnutrition: A prospective study. Am J Clin Nutr 1998; 67:940-5.

15. Gaboulaud V, Dan-Bouzoua N, Brasher C, Fedida G, Gergonne B, Brown V. Could Nutritional Rehabilitation at Home Complement or Replace Centre-based Therapeutic

Feeding Programmes for Severe Malnutrition? J Trop Pediatr 2007;53:49-51 Available

from: http://msf.openrepository.com/msf/bitstream/10144/21177/2/gaboulaud.pdf. [Last

accessed on 2009 Sep 15].




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16. Schneideman I, Bennett FJ, Rutishauser IH. The Nutrition Rehabilitation Unit at Mulago

Hospital-Kampala: Development and Evaluation, 1965-67. J Trop Pediatr Environ ChildHealth 1971;17 Monograph 13, 25-34. (54).

17. Beghin ID, Viteri FE. Nutritional rehabilitation centres: An evaluation of their performance.J Trop Pediatr Environ Child Health 1973;19:403-16.

18. Kadam DD, Kulkarni RN, Subramanium P. Anthropometric and socio-economic profile of children referred to nutritional rehabilitation centre. Indian Pract 2001;54:476-85.

19. Beghin ID. Nutritional rehabilitation centers in Latin America: A critical assessment. Am J

Clin Nutr 1970;23:1412-7.

20. Gueri M, Andrews N, Fox K, Jutsum P, St Hill D. A supplementary feeding programme for

the management of severe and moderate malnutrition outside hospital. J Trop Pediatr

1985;31:101-8.

21. Brewster D. Improving quality of care for severe malnutrition. Lancet 2004;363:2088-9;author reply 2089.

22. Collins S. Community-based therapeutic care- a new paradigm for selective feeding innutritional crises: Humanitarian Policy Network paper 48. London: Overseas Development

Institute; 2004.

23. Grobler-Tanner C, Collins S. Community therapeutic care (CTC): A new approach tomanaging acute malnutrition in emergencies and beyond. Washington DC: Food and

Nutrition Technical Assistance Project, Academy for Educational Development; 2004.

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experience in Western Darfur. In: Humanitarian Policy Network, ed. Humanitarian

Exchange. London: Overseas Development Institute; 2005. p. 20-2.

Background:

The state of Madhya Pradesh has 1.3 million severely malnourished children. Nutrition

rehabilitation centers (NRCs) were started in the state to control severe malnutrition and decreasethe prevalence of severe malnourished children to less than 1% among children aged 1–5 years.

Materials and Methods:






























The present study was conducted from November 2008 to October 2009; 100 children admitted

to seven different NRCs in Indore and Ujjain divisions of Madhya Pradesh were observed during

their stay at NRCs and the follow-up period to analyze the effect of interventional measures onselect anthropometric indicators. Mothers of the children were interviewed on health issues and

therapeutic feeding practices at the NRCs using a predesigned and pretested interview schedule.

Results:

The study group consisted of 48 boys and 52 girls; 60% were between 13 and 36 months of age.

93 children were analyzed for anthropometric indicators following a dropout rate of 7%. Astatistically significant difference was obtained between the weight of children at admission and

discharge (t =14.552, P <0.001); difference of mid upper arm circumference (MUAC) at

admission and discharge was statistically significant (t =9.548, P <0.001). The average weightgain during the stay at the centers was 9.25 ± 5.89 g/kg/day. Though the number of severe

malnourished children decreased from 85 to 43 following the stay at NRCs (χ 2 = 44.195,

P <0.001); 48.78% of the children lost weight within 15 days of discharge from the NRCs.

Dropout rates of 9.89%, 23.07%, 42.65%, and 61.76% for the study group were obtained duringthe follow-up period of 6 months for the four follow-up visits conducted 15 days, 1, 3, and 6

months after discharge. The mothers of the children lacked adequate information on health issues

and composition and preparation of therapeutic diets at the centers.

Conclusion:

The NRCs were effective in improving the condition of admitted children, but the effects were

not sustained following discharge due to high drop-out rate and lack of adequate parentalawareness. There is an urgent need to link these centers with community-based models for

follow-up and improve health education measures to maintain the gains achieved.

Keywords: Nutrition rehabilitation centers, severe acute malnutrition, therapeutic feeds

Go to:

Introduction

The state of Madhya Pradesh has the largest number of malnourished children in India; 6 million

children under five are malnourished including 1 million moderately malnourished and 1.3

million severe malnourished children.(1) To combat this menace, the Government of MadhyaPradesh initiated the bal sanjeevni drive in the year 2001 with support from United Nations

Children Fund (UNICEF) aimed at identifying and treating malnourished children. To prevent

deaths among severe malnourished children identified under the drive, the Government further started the Nutrition rehabilitation centers (NRCs) under the Bal Shakti Yojna with support from

UNICEF. The objectives of the programme are to control malnutrition among the children aged

1–5 years in the state and to bring down the percent of severe malnourished children to less than1%.(2)

The first of such centers was set up in 2007 and in a short span of 2 years the number of such

centers has increased to 175. The inputs being put in the NRCs have to be adequately analyzed to

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evaluate whether the desired objectives are being fulfilled. The present work tries to analyze the

effect of the NRCs in improving the health and nutritional status of severe malnourished children

admitted at the centers by studying the effect of the interventional measures on the admittedchildren and the effect of health education measures undertaken at the centers.

Objectives

1. Evaluate the effect of nutritional interventional measures undertaken at NRCs in

improving the nutritional status of admitted children through review of select

anthropometric indicators at the time of admission and discharge and during their stay atthe centers.

2. Follow-up the study group after discharge to check the compliance level among

beneficiaries to recommended follow-up visits and assess the effect on nutritional statusthrough review of select anthropometric indicators following discharge.

3. Ascertain the awareness and knowledge amongst mothers of the admitted children

regarding the practices followed at NRCs during their stay at the centers.

Functioning of NRCs

At the centers nutritional and medical intervention (appropriate antibiotics, deworming tablets,

iron supplementation, and micronutrients) is provided to the children. Severe malnourishedchildren are recognized in their respective localities by the Anganwadi Workers (AWWs) and

brought to the centers by the AWWs. An incentive of Rs 100 is provided to the AWW for

counseling of the mother to stay at NRC for 14 days at the time of admission. At NRCs, the

children are admitted and nutritionally rehabilitated for a minimum period of 14 days(2) usingtherapeutic feeding diets (F-75, F-100 and lactose free diet) prepared using locally available

foodstuff. If needed the children are medically rehabilitated as per the Indian Academy of

Pediatrics (IAP) protocol for severe malnourished children.(3) Supervised feeding of therapeuticdiets is done by the NRC staff (Feeding Demonstrators and Cooks) and medical intervention is

provided by the doctor in charge and the nurses at the centers. Though designated for severe

malnourished children, moderate and mild malnourished children are also admitted if there areassociated medical complications. Anthropometric indicators [weight, height, and mid upper arm

circumference (MUAC] are monitored to observe the effect of interventional measures on the

health status of the admitted children. Anthropometric assessment of the children is done by the NRC staff using standard validated measurement techniques. Weight of the children is taken

using electronic weighing scales (Seca: GMBH and company; model number 3341321008),

length using length boards (Seca: GMBH and company; model number 2101821009), and

MUAC measured by an MUAC tape designed by UNICEF and based on Shakir's tape for measuring MUAC.

The mothers of the children are made to stay at the centers where counseling sessions focusing

on health and nutrition aspects are conducted for them. The mothers are also provided hands on

training on composition and preparation of the therapeutic diets and given compensation for daily wage loss as per guidelines during their stay at the NRCs.(4)









A sum of Rs. 90 per child is allocated/day during their stay at the centers. Out of this, Rs. 25 is to

be spent for the food of the child and Rs. 65 to be handed over to the mother compensating for

her wage loss.(4)

The children are discharged after a minimum period of 14 days, provided the child does not

show any obvious signs of infection or edema, has received the stipulated amount of micronutrients, is gaining at least 8–10 g/ kg/ day, and the mother has improved understanding of

correct feeding practices. The children are again brought to the center by the AWWs on thedesignated follow-up dates at 15 days, 1 month, 3 months, and 6 months following discharge

from the NRCs wherein the AWWs are paid an incentive of Rs. 100 for bringing the child for

each follow-up visit. The mother also receives a sum of Rs. 65 to compensate for her daily wageloss. The same anthropometric measurements are taken on the follow-up visit and the child

treated for medical conditions; the child is also readmitted if needed.

Go to:

Materials and Methods

The present study was conducted in seven NRCs located across six districts in Indore and Ujjain

divisions of the state of Madhya Pradesh from November 2008 to October 2009 [ Figure 1]. At

the time of initiation of the study, Indore and Ujjain divisions had 48 functional and 7

nonfunctional NRCs. 15% of the operational NRCs were randomly selected for the study. Owingto time constraints and the 6-month follow-up period involved, the study was conducted on a

predecided sample size of 100 children aged between 0 and 60 months admitted to the selected

NRCs. The study design was prospective, wherein 100 children were recruited from the seven NRCs and were then followed up for the period of 6 months (incorporating four follow-up visits

during this period as stated earlier) to assess the nutritional status during the period of initial stay

and the entire follow-up period using available records of anthropometric indicators of theadmitted children recruited in the study at the NRCs. Initial recruitment of the children was done

during the months of December 2008–January 2009 and the follow-up period extended up to

July 2009. Children were recruited from the different NRCs depending upon the bed capacity

and the patient turnover rate at the centers during the study period [ Table 1]. The seven selected NRCs were visited by the investigators at intervals of 15 days during the months of December

2008–January 2009 and all children admitted at that particular day of the visit were included in

the study. Thus, more children were recruited from centers with higher bed capacity and higher admission rates. Once the figure of 100 was achieved the process of recruitment was stopped.

Figure 1

Map showing the selected study districts in the state of Madhya Pradesh. The study districts:Dewas, Dhar, Indore, Khandwa, Khargone and Ujjain



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Table 1

Selected nutrition rehabilitation centers and corresponding study subjects

Weight at the time of admission and discharge and daily weights were recorded from the NRCregisters; average weight gain was calculated to see if it was in accordance with the available

guidelines.(5) Appropriate statistical tests were applied to ascertain any significant difference

between the mean weights at discharge and the mean weight at admission for the study group. In

addition, the MUAC and grades of malnutrition at admission and discharge were also recordedand the average duration of stay at the centers studied to establish any difference amongst the

different age groups.

The children included in the study were followed up for 6 months to observe the compliance

during the follow-up period; follow-up records at the centers were analyzed to calculate thenumber of subjects with loss of weight at each follow-up visit, and the mean loss of weight

compared to the previous follow-up visit.

A predesigned and pretested semistructured interview schedule was used to interview themothers of the admitted children on awareness regarding government programmes focusing on

nutrition, basic concepts of nutrition, etiologies of malnutrition, and the impact of hands on

training provided at the centers, which focused on the composition and preparation of therapeutic

diets at the centers.

The data were entered into Microsoft excel spreadsheet and analyzed using SPSS version 17.

Statistical tests such as t -test, χ 2 test, and ANOVA were applied wherever needed.

Go to:

Results

Sociodemographic profile of participants

The study group included 48 boys and 52 girls. 40% of the children were in the age group of 13–

24 months (19 boys and 21 girls) and 20% in the age group of 25–36 months (12 boys and 8girls). The mean age duration for the entire group was 23.95 ± 13.68 months; for boys 26.29 ±

13.18 months and for girls 21.75 ± 13.94 months. 41% of the study population belonged to thescheduled caste (SC) group and 25% each to the other backward classes (OBC) and scheduled

tribes (ST). 63% of the parents of the admitted children were illiterate, 15% had received

education up to primary school, and 0.5% of the parents were graduates. 58% of the parents of

the admitted children were daily wage laborers, 14% were farmers, while 40% of the motherswere housewives. Families of 99% of the study subjects fell in Grade VI (below poverty line)










and Grade V (poor) socioeconomic class based on Agarwal's modification of the original

Prasad's classification.(6)

Effect on selected anthropometric Indicators of the admitted children during

stay at the NRCs

Analysis of the admitted children based on weight

A total of 93 children were included in the analysis: 45 (48.39%) boys and 48 (51.61%) girls

were analyzed for effect of nutritional interventional measures on anthropometric indicators as 6children (3 boys and 3 girls) did not stay at the centers for the entire duration of 14 days and 1

girl was referred to another health care setting. 37.63% were in the age group of 13–24 months

and 21.51% in the age group of 25–36 months. The overall mean weight of admission for thesechildren was 6.51 ± 2.04 kg; for boys 6.89 ± 1.96 kg and for girls 6.15 ± 2.08 kg. The mean

weight at discharge for the study group was 7.16 ± 2.13 kg; for boys 7.49 ± 2.08 kg and for girls

6.86 ± 2.16 kg. A statistically significant difference was observed between the mean weight at

discharge and the mean weight at admission for the study group (t =14.552, P <0.001) and for boys (t =9.904, P <0.001) and girls (t =10.475, P <0.001) separately [Table 2].

Table 2Mean weights at admission and discharge (n=93)

The average weight gain for the study group during their stay at the centers was 9.25 ± 5.89g/kg/day; for boys the average weight gain being 8.29 ± 5.20 g/kg/day and for girls 10.14 ± 6.39

g/kg/day. An average weight gain of at least 8 g/kg/day is considered to be adequate for a childduring stay at the residential therapeutic centers.(5) 50 children (20 boys and 30 girls) had an

average weight gain of >8 g/kg/day, while 43 had a weight gain of <8 g/kg/day [Table 3].

Table 3Age wise distribution for the average weight gained (n=93)

At the time of admission, 85 (91.4%) children were severely malnourished (Grades III and IV),

while 08 (8.6%) children suffered from moderate or mild malnutrition (Grades I and II).(7) 43

(46.24%) children were still severely malnourished (Grades III and IV), while 50 (53.76%)children were suffering from moderate or mild malnutrition (Grades I and II) at discharge.



















McNemar's chi-square test was applied and the difference between children severely

malnourished at the time of discharge as compared to admission was observed to be statistically

significant (χ 2=44.195, P <0.001) [Table 4].

Table 4

Severely malnourished children at the time of admission and discharge (n=93)

Analysis of the admitted children based on MUAC

MUAC data were analyzed for 75 children. Six children were not included because of default,one child had been referred to another health care facility and MUAC was not measured in

children less than 6 months (seven in number). Further 11 children from one particular studycenter were not included in the analysis as the center staff did not measure MUAC at discharge.

The mean MUAC at admission was 11.32 ± 1.18 cm and at discharge it was 11.94 ± 1.38 cm.The difference was observed to be statistically significant (t =9.548, P <0.001). The mean MUAC

for the boys at admission was 11.33 ± 0.98 cm and at discharge it was 11.87 ± 1.01 cm, which

was statistically significant (t =6.876, P <0.001). Similarly for girls the mean MUAC at admissionwas 11.31 ± 1.38 cm, at discharge it was 12.01 ± 1.33 cm, the observed difference being

statistically significant (t =6.723, P <0.001).

Duration of stay at the NRCs

The average duration of stay at the NRCs was 13.81 ± 2.73 days, for boys it was 14.73 ± 1.98

days and for girls it was 14.13 ± 1.20 days. 86 (92.47%) of the children in the study group hadstayed at the NRC at the centers for at least 14 days. No statistically significant difference was

observed among the different age groups with respect to duration of stay at the centers ( F =1.208,

P =0.312).

Analysis of follow-up data

From the 93 children for which initial anthropometric data were analyzed, 2 children were

excluded because of readmission on the first follow-up visit; thus, a total of 91 children were

included for the follow-up analysis. Since there was no uniformity amongst the different studycenters regarding the recording format for anthropometric indicators during follow-ups, only

weight of the children at the various follow-ups was included in the final analysis. For the third

and fourth follow-ups, 9 children from one center were excluded as the center had shifted over to

the new follow-up pattern of 2 months duration.(8) One NRC closed down during the studyduration; so the 13 children admitted to this particular center did not receive the third and fourth

follow-ups and hence were excluded from the final analysis for the last two follow-ups; a child










was excluded as the child was transferred to another hospital setting. Thus, a total of 68 children

were analyzed for the last two follow-ups [Table 5].

Table 5Age and sex wise distribution of children at the different follow-ups

Of a total of 91 children available for analysis for the first two follow-up visits, 82 children

reported for the first follow-up visit and 70 for the second. Similarly of the 68 children availablefor analysis for the third and fourth follow-up visits, 39 children reported for the third and 26

children for the fourth visit. Dropout rates of 9.89%, 23.07%, 42.65%, and 61.76% were

obtained for the four follow-up visits conducted 15 days, 1 month, 3 months, and 6 months from

the day of discharge as per recommended guidelines. This dropout rate at each follow-up visitwas found to be statistically significant (χ 2=61.106, P <0.001). If calculated from the baseline

data of 100 children, the dropout rates would be 18%, 30%, 61%, and 74% for the four follow-

ups.

Though there was an increase in mean weight of the children who returned for the follow-upvisits, it was offset to a certain extent by the loss of weight experienced by some children in the

study group. The loss of weight was maximum immediately, following the period of discharge as

48.78%, had lost weight on the first follow-up visit, a progressive increase in proportion of children gaining weight was noted in children who turned up for all the four visits [ Table 6].

Table 7 outlines the mean weight at each follow-up visit and also provides details on the

proportion of the children (mean weight loss) who had lost weight during each follow-up visit ascompared to the weight during the previous follow-up visit.

Table 6

Proportion of children with weight gain and weight loss at each follow-up visit

Table 7Details of follow-up visits with mean weight and proportion of children with weight loss at each

follow-up visit



















Knowledge and awareness among mothers of beneficiaries at the centers

Awareness regarding community programmes on nutrition and concepts of nutrition

Though 36% of the mothers were aware of the existence of NRCs, most of them were ignorant

about the actual name of the center. 3% had heard about the Bal Shakti Programme, 7% hadsome knowledge about the various types of nutrients and their importance, 2% correctly knewabout the preparation and use of Oral Rehydration Solution (ORS), while 23% had inadequate

knowledge about its use. 6% of the mothers had proper knowledge about the clinical symptoms

of vitamin A deficiency.

Awareness regarding etiology of malnutrition

92% of the mothers had no knowledge about the etiologies of malnutrition. Inadequate diet and

poor quality of food were considered to be the main reasons responsible for malnutrition by 4%

mothers each with repeated infections and lack of immunization being the other contributing

factors.

Knowledge regarding therapeutic feeding practices at NRCs

56% of the mothers said that they had been taught the preparation of the therapeutic diets at thecenters. Though majority of mothers had proper information regarding the time interval of feeds

at the NRCs, just 4% had correct knowledge (the correct constituents and correct method of

preparation) about F-75 diet and 2% about F-100. None of the mothers had any knowledge about

the lactose-free diets [Table 8].

Table 8

Knowledge regarding therapeutic feeding practices at NRCs (n=100)

Mothers also raised concerns about the reimbursement provided at the NRCs, the unavailability

of daily diets for them at the centers, and the absence of provision of food to the accompanying

siblings of the admitted child.

Go to:

Discussion

The study findings show that a major proportion of the admitted children belonged to the

marginalized population groups. The findings are in accordance with that of NFHS-III, which

states that children belonging to the SC, ST, and OBC and that those with illiterate mothers havethe highest rates of malnutrition.(9)












An initial dropout rate of 7% was noted in the present study. In a study in Burkina Faso among

1322 children dropout rates of 8.5% were noted.(10)

Weight has been taken as the main anthropometric measure as an improvement in weight of severe malnourished children has the most significant effect in reducing the mortality among

them. The study findings reveal a statistically significant difference between the mean weight atdischarge and the mean weight at admission for the entire study group (t =14.552, P <0.001) and

for boys (t =9.904, P <0.001) and girls separately (t =10.745, P <0.001). Colecraft et al . in a studyat four day care NRCs also reported a significant increase in weight for age for the admitted

children.(11)

The average weight gain for the entire study group was 9.25 ± 5.89 g/kg/day, which iscomparable to results observed by Savadago et al . in a study at Burkina Faso which reported an

average weight gain of 10.18 ± 7.05 g/kg/day;(10) findings reported by a set of studies in

Bangladesh comparing inpatient, day care and home-based treatment for severe malnourished

children observed an average weight gain of 11 g/kg/day for the inpatient group.(12 – 14)

A recovery rate of 53.76% (children with average weight gain of more than 8 g/kg/day) was

observed amongst the study group; recovery rate of 52.7% using the above international

standards was obtained by Gaboulaud et al . in a study comparing therapeutic feeding centers

(TFC) care, TFC plus home-based care, and only home-based care amongst 660 children in theTFC group.(15)

The difference between MUAC at discharge and at admission was found to be statistically

significant for the entire study group (t =9.548, P <0.001), for boys (t =6.876, P <0.001) and girls(t =6.723, P <0.001). MUAC is very easy to measure and hence should be used appropriately and

judiciously for monitoring children at the NRCs.

Though the number of children suffering from severe malnutrition decreased from 91.4% to

46.24%, the difference being statistically significant (χ 2=44.195, P <0.001), 43 children were stillin the high risk group at the time of discharge. Appropriate criteria must be designed which

specifically adopt a target weight for each child with the child being discharged once the target

weight is achieved provided the child has been appropriately rehabilitated with nutritional and

medical measures.

The median duration of stay at the centers was 14 days, which is much less than earlier

programmes for children with severe Protein Energy Malnutrition (range from 6 weeks to 8

months).(16 – 18) The short duration of stay not only decreases costs but also minimizes the

absence of mothers from their homes which has important implications at the society level.Effectively, the duration of stay needs to be balanced between the chances of cross exposure to

infection and the readiness of the mothers to effectively manage their children at home.

The study findings reveal increasing drop outs rates with each successive follow-up. Acomprehensive review by Ashworth et al . comparing inpatient, outpatient, and home-based care

and home-based care alone in Bangladesh revealed a dropout rate of 23% for the inpatient group

over a 12 month period, the highest in the three groups.(12 – 14) The low compliance during























follow-up visits limits the overall success rate of the programme. Effective measures are needed

to improve the compliance rates for follow-up visits. Community mobilization needs to be done

and the community should be made aware of the functioning of the centers. Creating a network of outreach workers from the NRCs or selecting volunteers on the lines of the Revised National

Tuberculosis Control Programme (DOTS provider) from different localities who can monitor the

follow-up dates of the discharged children and help the AWWs in decreasing the number of dropouts.

The mothers attending the centers had limited knowledge regarding the basic concepts of

nutrition, the Government Health Programmes on nutrition and the composition and preparation

of therapeutic feeds at the centers. Mothers are specifically kept at the centers so that they can sothat they can be integrated into the effective care of the children and are taught the preparation of

the therapeutic diets from locally available material. Surprisingly, this fact is often ignored and at

the centers and much attention is paid to the improvement in nutritional status of the children,which is essentially considered to be the criteria of the success of the programme. Beghin in his

critical assessment of 21 NRCs across 6 Latin American countries found nutrition education to

be lacking at most of the centers he visited.(19)

44% of the mothers said that they had not been taught the preparation of the therapeutic diets.This is clearly reflected in the fact that 48.78% of the children had lost weight within 15 days of

discharge. The period immediately following discharge is most important as mothers find it

difficult to comply with the intervention strategies taught at the center, which indirectly lowersthe compliance to follow-up visits. Educating the AWWs on the feeds prepared at the centers can

help the mothers when they go back to their homes and help maintain the growth achieved at the

centers. The loss of children during follow-up visits can only be reduced to a certain extent and

hence nutrition education measures must be stressed upon during the initial stay at the centers.Counselling sessions focusing on the general health education measures should be undertaken to

prevent malnutrition and mothers should be mandatorily made to prepare the therapeutic diets atthe centers.

Most of the mothers in the study belonged to poor socioeconomic background. This limits the

accessibility to even cheap locally available food, as outlined by earlier studies,(11) hence

providing some sort of assistance in the form of adequate ration to the mothers used in preparing

of the therapeutic feeds lasting till the next follow-up can be initiated, alternate arrangements of providing that ration to Anganwadi Centers of the areas can be done from where the feeds can be

distributed to the mothers of the affected children. Often in our society mothers do not enjoy the

rights to decide what to feed in the family, hence involving fathers and other caregivers of thefamily in the programme should be undertaken.

An important area of debate is the amount of reimbursement paid to the mothers during their stay

at the centers. The present amount of Rs. 65 per day is much less as compared to the minimum

daily wages presently paid through the labour schemes of the Government of India. In addition,mothers at some centers had to be provided food from sources other than the hospital mess. The

amount spent on food was deducted from the compensation provided for the daily wage loss;

also lack of provision of food to the accompanying children was an important issue raised by themothers of the admitted children. These factors can adversely affect the compliance of mothers







at the centers. Providing food separately to the mothers and accompanying children should be

undertaken so as to prevent food sharing between the mothers and the accompanying siblings. If

food is to be made available from outside sources the amount incurred should not be deductedfrom the compensation for the daily wage loss.

Available literature also points toward the inherent weaknesses in the set up: Limited inpatientcapacity and lack of enough skilled staff to treat the large number of children needing care.

(20,21) The state of Madhya Pradesh has at present 1.3 million severe malnourished children(1)with 175 operational NRCs. Available guidelines state establishing 20 bedded NRCs at district

level and 10 at block level.(8) Assuming all the centers to be 20 bedded the number of children

treated every month works out to be 40 (20 children for 14 days each). Thus in one year thenumber of children who can be treated at the centers comes as 84,000. To treat the entire 1.3

million children it would take approximately 15.5 years, assuming no failure or readmission

rates. If the 1 million moderately malnourished children are also included in the purview, itwould take another 12 years to achieve the objective.

Thus NRCs cannot be the only tool to combat malnutrition; the study results show that the NRCshave had a positive impact on the selected anthropometric indicators of severe malnourished

children but lag behind in the educational aspect and ensuring proper follow-up visits. Linking of NRCs with the community-based Core Model of Management of severe malnourished children

needs to be put into place as soon as possible.(22,23) This model is the current protocol

envisaged by the World Health Organization and provides a framework for an integrated PublicHealth response to curb malnutrition, treating most patients with severe malnutrition at home

with inpatient care being reserved for those with acute complications, thereby minimizing the

cost to families and maximizing access to treatment.(24)

However, establishment of such a model of treatment would require large resource mobilization

both in terms of money and human resource with special emphasis on training aspects along withthe motivational issues involved. A delicate balance needs to be achieved between both the

modalities of treatment, and until the community-based model is put in place NRCs will continueto act as a major tool to adequately and effectively address the glaring issue of malnutrition in

the state of Madhya Pradesh and the country.

The study is prone to observer bias as it is based on secondary data. Selection bias was

introduced in the study because of the purposive sampling used to recruit the study children. Thestudy has its limitations in that it was conducted in a limited group of subjects and was restricted

to a few districts of the state. Studies with bigger sample size selected from NRCs across the

state of Madhya Pradesh will give a more composite view of the actual effect of the NRCs in

checking the prevalence of malnutrition in the state.

Go to:

Acknowledgments

The authors are thankful to Dr. Satish Saroshe (Post Graduate Student), Department of

Community Medicine forhis help in the completion of the study.




















Go to:

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

Go to:

References

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20]. Available from:http://www.ndtv.com/news/india/madhya_pradeshepicentre_of_hunger.php .

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accessed on 2009 Aug 20]. Available from:http://www.mp.gov.in/health/nrhm/Innovativenrhm.pdf .

3. Bhatnagar S, Lodha R, Choudhury P, Sachdev HP, Shah N, Narayan S, et al. IAP guidelines

2006 on hospital based management of severely malnourished children (adapted from the WHOGuidelines) Indian Pediatr. 2007;44:443–61. [PubMed]

4. Bal Shakti. New York, USA: UNICEF; 2008. Guidelines for Management of severely

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malnourished. (Draft copy) 2008

6. Agarwal A. Social classification: The need to update in the present scenario. Indian JCommunity Med. 2008;33:50–1. [PMC free article] [PubMed]7. Park K. 20th ed. Jabalpur: Banarsidas Bhanot; c2009. Textbook of Preventive and Social

Medicine. Preventive Medicine in Obstetrics, Pediatrics and Geriatrics: Growth Charts used in

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9. Mumbai: IIPS, ORC Macro; 2005. International Institute of Population Sciences. NationalFamily Health Survey –3.

10. Savadogo L, Zoetaba I, Donnen P, Hennart P, Sondo BK, Dramaix M. Management of

severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso. Rev

Epidemiol Sante Publique. 2007;55:265–74. [PubMed]11. Colecraft EK, Marquis GS, Bartolucci AA, Pulley L, Owusu WB, Maetz HM. A longitudinal

assessment of the diet and growth of malnourished children participating in nutrition

rehabilitation centres in Accra, Ghana. Public Health Nutr. 2004;7:487–94. [PubMed]12. Khanum S, Ashworth A, Huttly SR. Controlled trial of three approaches to the treatment of

severe malnutrition. Lancet. 1994;344:1728–32. [PubMed]

13. Ashworth A, Khanum S. Cost-effective treatment for severely malnourished children: Whatis the best approach? Health Policy Plan. 1997;12:115–21. [PubMed]



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23. Grobler-Tanner C, Collins S. Washington DC: Food and Nutrition Technical AssistanceProject, Academy for Educational Development; 2004. Community therapeutic care (CTC): A

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24. Guerrero S, Mollison S. Humanitarian Policy Network, ed. Humanitarian Exchange. London:Overseas Development Institute; 2005. Engaging communities in emergency response: The CTC

experience in Western Darfur; pp. 20–2.

Articles from Indian Journal of Community Medicine : Official Publication of IndianAssociation of Preventive & Social Medicine are provided here courtesy of Medknow

Publications

Nutrition Rehabilitation Centre gets global encomiums

UNICEF team makes surprise check of Bairagarh Centre

A five-member UNICEF team led by Dr. Steve Collins, president, Valid Nutrition of Ireland

reached Bhopal recently and made a surprise check of Nutrition Rehabilitation Centre at

Bairagarh Hospital in Bhopal. During the inspection, Dr. Collins was so much impressed by


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http://msf.openrepository.com/msf/bitstream/10144/21177/2/gaboulaud.pdf






http://mp-watch.blogspot.in/2010/04/nutrition-rehabilitation-centre-gets.html



caretaking of malnourished children, sanitary arrangements and centres functioning that he wrote

in his remarks 'I have been visiting NRCs for over 20 years and this is the best-run centre I have

ever visited. Congratulations.' The team has termed the facilities at the NRC as of international

level. Dr. Collins was accompanied by Valid International's Special Project Officer Dr James

Lee and officials of UNICEF's Delhi, Patna and Bhopal units.

Dr. Collins and Dr. Lee enquired mother of every child admitted at the centre about the available

facilities, caretaking, diet supply and increase in the weight of malnourished children. The team

also visited the kitchen enquired the staff about latest techniques, diet system, admission process

and other details and expressed satisfaction and happiness over the arrangements.

It may be mentioned that malnourished children from Bairagarh, Gandhi Nagar and nearby areas

are taken care of at Bairagarh NRC. The team has also lauded the efforts put in by Bairagarh

Civil Hospital's superintendent Dr. Amita Dubey and other staff members as well as local public

representatives. Praise of an Nutrition Rehabilitation Centre from an international organisation is

a shot in the arm of the state government at a time when it is trying for victory over malnutrition.

The team comprised Dr. Mohammad, Dr. Deepti Shrivastava, Smt. Kajli, Smt. Raj from

UNICEF Delhi, Dr Alok I Ranjan of UNICEF Patna and Smt. Rashmi Patel, Smt. Soumya, Smt.

Vandana and Smt. Kavita of UNICEF Bhopal.

Nutrition Rehabilitation Centre

Women and their children at NutritionRehabilitation Centre

Nutrition Rehabilitation Centre is a joint initiative of Department of Health and Department of Women and Child Development. Launched in July 2007 in District Hospital, Morena, and

Community Health Centre, Joura, the centre covers poor and marginalised population in four

development blocks.



Objectives

• Reduction of severe malnutrition parentage

• Reduction of moderate malnutrition

• Reduction of under five mortality rate

• Reduction of malnutrition up to 100

• Improvement of sex ratio

Activities

• Early Identification of moderate malnutrition

• Early identification severe malnourished children and their admission in NRC

• Meetings with malnourished children and parents in difficult areas

•

Nutritional advice to parents of malnourished children

• Promotion of infant and young child feeding

• Promotion of safe water, hygiene and sanitation

• Counselling of mother, father and mother-in-law

• Formation of clubs of mothers of malnourished children at anganwadi centres

Documents

Press Information Bureau