A presentation on severe acute malnutrition and nutritional rehabilitation center. Various preventive, promotive, and curative aspects of SAM are discussed in this presentation.

1. Severe Acute Malnutrition &
Nutrition Rehabilitation Center
Presenter – Dr. Atul Gupta
Moderator – Dr. Poonam Khanna

2. Outline
Introduction
Burden of disease
Determinants of Malnutrition
Management
Community Based Management
Nutrition Rehabilitation Centre
Policies and Programmes

3. Introduction
Malnutrition is a universal problem that affects most of the
world’s population at some point in their lifecycle, from infancy
to old age.
Affects all geographies, all age groups, rich and poor people and
both sexes.

4. Introduction
Undernutrition explains around 45% of deaths among children
under five, mainly in low and middle-income countries. *
The health consequences of overweight and obesity
contribute to an estimated 4 million deaths (7.1% of all
deaths)
120 million healthy years of life lost (DALYs) across the
global population. *
* Global nutrition report 2018

5. Malnutrition
 Refers to deficiencies or excesses intake of energy and/or
nutrients in a person.
As per WHO
Imbalance between the supply of nutrients &
energy and the body’s demand to ensure growth,
maintenance and specific functions.

6. Undernutrition – Inadequate
consumption, poor absorption or
excessive loss of nutrients.
 Includes - stunting, wasting,
underweight and micronutrient
deficiencies. Most common
form of Malnutrition in
developing countries
 Overnutrition – Overindulgence or
excessive intake of nutrients.
 Includes overweight, obesity.
More Common in developed
countries

7. Protein Energy Malnutrition :
 Range of pathological
conditions arising from lack, in
varying proportions of proteins
and calories.
Marasmus :
 Weight for age < 60% expected
Kwashiorkar :
 Weight for age < 80% + Edema
Marasmic Kwashiorkar:
 Weight for age < 60% expected
+ Edema

8. Indicators of Malnutrition

9. Burden of Malnutrition
World wide
150.8 million children are stunted.
50.5 and 38.3 million children are wasted and overweight respectively.
88% of countries experience more than one form of malnutrition, 29%
having high levels of all three forms.
3.62% of children under five are both stunted and wasted.
1.87% of under - 5 experience both stunting and overweight.
Source: UNICEF/World Health Organization (WHO)/World Bank Group: Joint child malnutrition estimates, 2017.

10. Burden of malnutrition
198.4
150.8
30.1
38.3
0
50
100
150
200
250
2000 2004 2008 2012 2016
Children
affected,
millions
Number of children affected by stunting and overweight globally,
2000–2017
Stunting Overweight
Source: UNICEF/World Health Organization (WHO)/World Bank Group: Joint child malnutrition estimates, 2017.

12. Indian scenario
India had 195.9 million ( 23.8%) undernourished people of
global burden.
35% of all under 5 deaths are due to undernutrition as
underlying cause.

13. 38.4
21
35.7
34.7
17.3
33.4
0
5
10
15
20
25
30
35
40
45
Stunting Wasting Underweight
NFHS 4 CNNS
Malnutrition Indicators in NFHS 4 and CNNS

15. Severe Acute Malnutrition
Defined as severe wasting and/ or bilateral pedal edema
• Severe wasting diagnosed as weight for height/ length <-3 SD of
WHO growth standards
• For children b/w 6 mo – 59 months , also defined as MUAC <11.5cm

16. Determinants of Malnutrition
Malnutrition
Inadequate dietary
intake
Disease
Immediate
causes
Outcome
Underlying
causes
Inadequate
access to
food
Inadequate
care of mother
and children
Insufficient
health
services
Unhealthy
environment
and unsafe
drinking
water
Food security
resources
• Income
• Dietary Diversity
• Quality of food
Inadequate
education/ lack of
Knowledge
Resources for Health
• Availability of public
health resources
• Sanitation
Source: from UNICEF 1990; Jonsson 1993; Smith, Haddad 2000 and Mehrotra 2003

17. Precipitating factors
Lack of food (famine, poverty)
Inadequate breast feeding / Delayed Complementary
feeding
Diarrhoea & malabsorption
Infections (TB , worms)

18. Management
• Children with SAM and
medical complications
Facility/Hospital
based care
• Children with SAM but
without medical
complications
Home/community-
based care

19. Case Management Flow
Case Identification (1. Active Screening 2. Passive Screening
3. Screening in OPDs )
SAM
Medical complications (any one)
1. Poor appetite
2. Visible severe wasting
3. Edema of both feet
4.Severe pallor
5. Lethargy, drowsiness, unconsciousness
Continually irritable and restless
6. Any respiratory distress
7. Signs suggesting severe dehydration in
a child with diarrhoea
Immediate referral to NRC
No Medical Complication
Refer to VHND or Sub- Center for
further assessment and counseling
by ANM
Transfer to Community based
program for SAM
management
No SAM
Nutritional
counselling
to mother/
caregiver
After discharge

20. Community based management
Aims to ensure increased access and care to large number of children
with SAM who do not require inpatient care.
Steps of management
1.Anthropometric assessment
2.Medical assessment
3.Appetite assessment
4.Nutritional treatment
5.Medicines
6.Health education
7.Follow up

21. Anthropometric assessment
Height: > 2 yrs by
using
stadiometer:
Recumbent length: < 2yrs
(By infantometer)
MUAC Measurement

22. Ready to use Therapeutic Food ( RUTF)
Powder based consumed as it with no dilution
Nutritive value 500 Kcal/Sachet

23. Ready to use Therapeutic Food ( RUTF)
Advantages
1. Provides all nutrients recovery and have higher
acceptability than F-100
2. Stored at room temperature, long shelf life.
3. No cooking required, no dilution required.
4. Child can consume on its own without any help
5. Reduces hospital stay period
Disadvantage
1. Costly. Full course treatment costs around $100 per child.

26. Nutrition Rehabilitation Centre
NRC -Facility based treatment care of children with severe
malnutrition.
Objectives of NRC:
 i) Improve access to basic preventive & curative services.
 ii) Encourage sustainable behavior change.
 iii) Support caring practices.
 iv) Stimulate social mobilization by the community to demand
better services & Accountability.

27. Services Provided at NRC
1
• 24 hour care and monitoring of the child
2
• Treatment of medical complications
3
• Therapeutic feeding
4
• Social assessment of the family to identify and address
contributing factors

28. 5
• Counseling on appropriate feeding, care and hygiene
6
• Demonstration and practice of preparation of
energy dense child foods using locally available,
culturally acceptable and affordable food items
7
• Follow up of children discharged from the facility

29. Phases of management in NRC
• Lasts for 1 - 2 days
• Starter Diet F - 75
Stabilization
Phase
• Lasts for 3 - 4 days
• Catch up diet F - 100
Transition
Phase
• 2 to 6 weeks
• Preparedness to feed at home
Rehabilitative
Phase

31. 10 Essential steps in treatment

32. Limitation of hospital based management
Limited inpatient capacity
 Late presentation of Child
 Prolonged Stay increase hospital cost
Increase risk of nosocomial infection
Other family members neglected and earning affected
Early discharge increase morbidity and mortality.

33. NRC in Chandigarh

34. Policies and Programmes

35. Poshan Abhiyan

37. Objectives

38. Under Poshan Abhyan

40. 4 point Strategies

41. Convergence

42. ICDS- CAS

44. Way Forward
Periodic Aggressive growth monitoring.
Upgrading of Anganwadi centres.
Improve co-ordination, home visits and outreach activities.
Targeting more on high risk groups.
More focus on caregivers counselling and education
Promoting home/locally based nutritive foods.
Improving WASH activities.