E D I T O R I A L

Nutrition Rehabilitation Centers and Locally Prepared Therapeutic Food in

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wenty years after initiating ‘Breastfeeding NRCs, in addition to curative care, special focus should
Policy’ in 1992 and 10 years after initiating the be on timely feeding, adequate and appropriate for
Global Strategy for ‘Infant and Young child children and on improving the skills of mothers /
feeding’ (IYCF) in 2002, we have to admit that caregivers on optimum age appropriate caring and
millions of under-five children in India suffer from feeding practices. Efforts are also to be made on capacity
Moderate acute malnutrition (MAM) and Severe acute building through counseling and practical
malnutrition (SAM) including edematous SAM (E-SAM). demonstrations on infant feeding, sensory stimulation,
As per the NFHS-3 (2005-06) data, 43% are underweight, play therapy, imparting tender loving care and so on. The
48% are stunted, 20% are wasted and 7.9% have severe ambience of the NRC should be warm, colorful and
wasting [1]. Due to the association of malnutrition with attractive.
morbidity and mortality, specialized treatment and
preventive interventions are required. SAM cases with In-patient management of children with SAM is
medical complications need to be managed and followed highly effective in reducing case fatality rates, but even
up in nutrition rehabilitation centers (NRCs). Active case under the best circumstances inpatient facility will not be
finding of the underweight children, utilizing growth able to handle the entire caseload in a given high priority
monitoring chart available in the Mother Child Protection area. Most states of India already have many NRCs, but
(MCP) Card and categorization as per weight for age some had none; Kerala recently started the first NRC in
(underweight), height for age (stunted) and weight for the tribal belt of Attappadi, Palakkad District in June, 2013.
height (wasted) are required for appropriate intervention. Other issues with respect to NRCs are long hospital stay
requiring the mother/caregiver to stay away from home
Malnutrition is usually noted in the stereotypic profile and the father missing work for many days, and the
of poverty, ignorance and illiteracy or natural calamities resultant practice of leaving against medical advice.
like war or famine but currently causal factors like ‘man-
made perception’ of lactation failure, abrupt breastmilk Implementation of the 10 steps of SAM management
withdrawal and early introduction of diluted formulae/ protocol often need to be modified as per the availability
diets are being increasingly identified [2]. Malnutrition of proxy preparations of F75, F100 and RUTF that are
being a ‘Bio-Psycho-Social Disorder’, biologic/organic adapted by NRCs in India [5]. Imported feeds of the above
causes, psychological disturbances in individuals/family preparations are considered not acceptable, feasible,
and or social factors are causative, and not necessarily affordable and sustainable in the Indian setting. Several
lack of food alone. proxy feeds based on whole strength milk, infant formula,
skimmed milk powder, cereal flour etc. are being tried in
NRC is a unit in a health facility where children with various NRCs in India [6-8].
SAM are admitted as per the defined admission criteria
and provided with medical and nutritional therapeutic care Outcome measures of NRCs include survival, default,
[3,4]. Discharge from NRC is to be based on attainment of discharge and cure rates (3,4). High default rates and low
target weight-gain of 15% from the admission weight and cure rates are of great concern in the present setting. 12
the child should continue to be in the nutrition NRCs from UP have reported very low mortality rate
rehabilitation program till she/he attains the cure weight (1.2%) and an average weight gain of 12.1 g/Kg/day, which
of >1 SD or 90% of the expected weight-for-height. In is commendable, but it is also reported that 53% had to be

INDIAN PEDIATRICS 19 VOLUME 51__JANUARY 15, 2014

discharged before recovery/attaining target weight for 2. Elizabeth KE. Changing profile of undernutrition and
discharge, and default rate was as high as 47% (5). Similar edematous severe acute malnutrition (E-SAM). Indian
observation has been made from other facilities as well [8]. Pediatr. 2012;49:843-4.
Recent experience from a tertiary care teaching hospital 3. World Health Organization (WHO) Guidelines for
Inpatient Treatment of Severly Malnourished Children.
was: 40.3% cure, 13.4% default and 5.9% mortality with 3
WHO, Geneva, Switzerland, 2003.
deaths out of the 67 enrolled occurring before getting 4. Indian Academy of Pediatrics (IAP). IAP Guidelines 2006
initiated on SAM management [7]. for hospital-based management of severly malnourished
A community-based program for the management of children (adapted from WHO Guidelines). Indian Pedaitr.
2007;44:443-61
SAM without medical complications and for those who
5. Singh K, Badgaiyan N, Ranjan A, Dixit HO, Kaushilk A,
are to be followed up after NRC care should be in place to
Kushwaha KP, et al. Management of children with severe
complement the services of NRCs. Moreover, each child acute malnutrition: Experience of nutrition rehabilitation
should be line listed and tracked in the community before centres in Uttar Pradesh, India. Indian Pediatr. 2014;
and after discharge using the available health care/ICDS/ 51:21-5 .
ASHA workers and the system of Mother Child Tracking 6. Kapil U. Ready to Use Therapeutic Food (RUTF) in the
System (MCTS)/mobile phone SMS. Research and management of severe acute malnutrition in India. Indian
development, and consensus on locally prepared Pediatr. 2009;46:381-2.
therapeutic food proxies as used in regional NRCs should 7. Elizabeth KE. Adoption of WHO Protocol for Hospital
Based Management of Severe Acute Malnutrition (SAM)
be considered as a national priority.
in Underfive Children – An Observational Study. SAT
Funding: None; Competing interests: None stated. Endowment Scheme Project Report. SAT Hospital, Govt.
Medical College, Thiruvananthapuram, 2013.
REFERENCES 8. Namidi RS, Kulkarni B, Radhakrishna KV, Shatrugna V.
1. International Institute for Population Studies (IIPS) and Hospital based nutrition rehabilitation of severely
Macro International. National Family Health Survey malnourished children using energy dense local foods.
(NFHS -3), 2005-2006. IIPS, Mumbai, India, 2007. Indian Pediatr. 2010;47:687-93.

INDIAN PEDIATRICS 20 VOLUME 51__JANUARY 15, 2014