Saving Lives of Children with Severe Acute MalnutritionSHIVPURI, India , 7 January 2011– Seven-month-old girl Durgesh Rawat weighed just four kilograms when she had an attack of pneumonia in March this year. “Durgesh is my second child and was born healthy.
But I fell ill right after delivery and couldn’t not breastfeed her. My mother-in-law had to look after the new born for six months,” says Ramkalibai who works at the agricultural field in her village Bilokala, 45 km from Shivpuri in the central Indian state of Madhya Pradesh.
By the time Ramkalibai recovered from her illness, Durgesh was extremely weak and suffered from perpetual fever. Ramkalibai’s husband Dhaniram Rawat works as a daily wage labourer in the village.
“The child was severely malnourished, just skin and bones and weighed less every successive month. She had an abnormally bloated and distended stomach, a typical symptom of an acutely malnourished infant. We were scared to even give her an injection for there was hardly any muscle visible,’’ recalls Devki Ojha, Anganwadi worker of Bilokala village.
Concerned with their critical condition, the elders agreed to admit Durgesh and Ramkalibai to the Nutrition Rehabilitation Centre (NRC) at the Shivpuri district hospital. NRC are facility based care units where severe acute malnourished (SAM) children below five years are admitted with their mothers for treatment.
An NRC at the District hospital is generally 20-bedded while at the block levels, the units attached to Community Health Centres and Primary Health Centres are usually 10-bedded. Feeding therapy, nutritional supplements and medicines are administered according to the guidelines of the World Health Organization and Indian Academy of Pediatrics.
Mothers stay with their children in the NRC and attend counseling sessions on how to take care of their children after they are discharged from the NRC. While Dr Nissar Ahmad, pediatrician at the Shivpuri NRC concentrated on improving Durgesh’s nutritional status, the child’s mother attended counseling sessions.
Feeding demonstrator at the ward, Preeti Mehta taught Ramkalibai the correct way of feeding Durgesh. “Before coming to the NRC, Ramkalibai fed the child milk through from bottle,” recalls Preeti.
“The child wouldn’t eat anything and the mother did not know what to feed her.’’ Ramkalibai was advised not to bottle-feed her seven-month-old daughter. “Complementary feeding should start after six months. We told her to start using the spoon and bowl and taught her the exact method of feeding Durgesh” says Preeti.
“She was told to feed the child after modifying whatever was being cooked at home for the adults khichdi, dal and rice, dalia, kheer, bananas, fruits. The mother was also counseled on the number of times to feed the child. She was trained on sanitation and cleanliness, ’’ adds Preeti.
After the end of second day at the NRC, Ramkalibai was asked to feed the child under the supervision of the feeding counselors. “I fed khichdi to Durgesh with a spoon and she started eating,’’ Ramkalibai recollects.
“Then I fed her bananas and dalia (broken wheat). My daughter’s eating habits changed in the next few days and she started gaining 40 grammes weight per day.’’ Ramkalibai was also told in detail about the benefits of personal hygiene by the NRC counselors.
“They told me to clean the utensils properly and wash my hands before feeding the child. I was also asked to bathe Durgesh every day and also keep her clothes and toys clean,’’ Ramkalibai said.
Children are kept for a minimum of 14 days at the NRC but if they fail to respond adequately during that time, the doctors extend their stay till they recover fully. Children with infections and other medical complications are treated by a pediatrician.
While Durgesh was discharged from the NRC after 17 days, another SAM child, Khushi of Indira Colony in Shivpuri town, had to be admitted for a second session. Khushi was 3-years-old and weighed 5.5 kg when admitted with her mother Parvati on October 30, 2009.
Khushi’s father works as a casual labourer in Shivpuri town. In two weeks of staying at the NRC, she gained 600 grammes. “Khushi came to us with a tuberculosis infection,’’ recalls NRC pediatrician Dr Nissar Ahmad.
“She couldn’t walk, suffered from night-blindness, was cranky and would not eat anything” says Dr. Ahmad. “SAM children are not just underweight. They come to us with fever and other common diseases like diahorrea, primary tuberculosis, measles, skin ailments, pneumonia and whooping cough,” he adds.
A SAM child is considered to be cured and discharged from the programme only after a 15 per cent weight gain from the day the baby was admitted to the NRC. “Khushi had gained very little weight and we wanted to keep her for a second session but her father took her away on November 13,’’ Dr Ahmad explained.
“However, she was brought back after the anganwadi worker convinced Dhani Batham and readmitted Khushi and her mother for a second session four days later. When she was discharged on December 2, her weight was 8.1 kg. The girl had gained 2.7 kg.’’
Proper care and follow up checks are required by the family members after the child is discharged from the NRC to keep track of the child’s nutritional status and to take corrective actions in case there is no improvement.
“The child is brought back to the NRC once every 15 days for the next two months for check-ups,’’ Dr Ahmad said. Durgesh was 4.7 kg at the time of discharge on 10 April this year, showing a gain of 700 grammes in 17 days at the NRC.
In June, she weighed 6.5 kg and by September the girl was a normal 7.4 kg. Khushi also showed remarkable recovery, completely cured of all diseases including primary tuberculosis. She was 9.1 kg two months after her discharge.
Her weight gain was consistent with no relapse due to strong follow-up services at the community level. A strong community outreach component is built into community care in order to provide both preventive and curative care when children get discharged from NRC and come back to their homes. NRC at the Shivpuri District hospital was one of the first NRCs in Madhya Pradesh set up in year 2006.
It was initiated and supported by UNICEF initially but today, the state has 224 such units attached to the district hospitals, Community Health Centres and Primary Health Centres are managed and supported by the State government under the National Rural Health Mission.
UNICEF provides technical support including training of doctors and para medical staff, monitoring of units, supervision and guidance and gap filling supplies.