NUTRITIONAL REHABILITATION

CENTRE (NRC)

DR. RITIKA BAKSHI

ASSISTANT PROFESSOR
DEPARTMENT OF COMMUNITY MEDICINE
AMRITA SCHOOL OF MEDICINE
FARIDABAD, HARYANA
Introduction
Malnutrition is a major public health concern in the country. To address
the issue of moderate and severe acute malnutrition (MAM & SAM)
among children under 5 years of age, integrated prevention and
treatment approaches are being implemented through:

• Community-based Management Program

• Facility-based Management Program (Through NRC)
Screening for SAM in the
Community
Comprehensive integrated package of services under
community based program for children with severe wasting
(SAM)
Appetite Test in community
settings
Appetite test helps in identifying SAM children with medical
complications who will need hospitalization.
Children who have good appetite can get nutritional rehabilitation in
community settings.
Appetite Test Feed
• Based on the nutritional needs, the suggested method of testing of appetite is as
follows:
1. For children 7–12 months: Offer 30-35 ml/kg of Catch-up diet. If the child takes
more than 25 ml/kg then the child should be considered to have good appetite.
2. For children >12 months: Feed locally prepared with the following food items
may be offered.
a. Roasted ground nuts 1000 gm
b. Milk powder 1200 gm
c. Sugar 1120 gm
d. Coconut oil 600 gm
How to prepare-
Take roasted groundnut & grind them in mixer.

Grind sugar separately or with roasted groundnut.

Mix groundnut, sugar, milk powder & coconut oil.

Store them in air tight container.

Prepare only for 1 week to ensure the quality of feed.

Store in refrigerator.
 HOW TO DO THE APPETITE TEST :

Do the test in a separate quite area.

Explain the procedure of the test to the mother

The mother is made to wash her hands.

The mother sits comfortably with the child on her lap and offers
the therapeutic feed.
Admission criteria for NRC
Nutritional Rehabilitation
Centre
• Nutrition Rehabilitation Center (NRC) is a unit in a health facility
where children with Severe Acute Malnutrition (SAM) are admitted
and managed. Children are admitted as per the defined admission
criteria and provided with medical and nutritional therapeutic care.
• Once discharged from the NRC, the child continues to be in the
Nutrition Rehabilitation program till she/he attains the defined
discharge criteria from the program.
Services provided at NRC
The services and care provided for the in-patient management of SAM children
include:
• 24 hour care and monitoring of the child.
• Treatment of medical complications.
• Therapeutic feeding.
• Providing sensory stimulation and emotional care.
• Social assessment of the family to identify and address contributing factors.
• Counseling on appropriate feeding, care and hygiene.
• Demonstration and practice- by -doing on the preparation of energy dense child
foods using locally available, culturally acceptable and affordable food items.
• Follow up of children discharged from the facility
Location and size of NRC
• NRC is a special unit, located in a health facility and dedicated to the
initial management and nutrition rehabilitation of children with
severe acute malnutrition.
• At a district hospital/medical college hospital, the NRC would have
10-20 beds and at a FRU/CHC the NRC would have 6-10 beds.

• The unit should be a distinct area within the health facility and should
be in proximity to the pediatric ward/inpatient facility.
The NRC should have the following:
• Patient area to house the beds; in NRC adult beds are kept so that the
mother can be with the child.
• Play and counselling area with toys; audiovisual equipment like TV,
DVD player and IEC material.
• Nursing station
• Kitchen and food storage area attached to ward, or partitioned in the
ward, with enough space for cooking, feeding and demonstration.
• Attached toilet and bathroom facility for mothers and children along
with two separate hand washing areas.
Human Resource
Principles of Management of
SAM in NRC
1. Stabilisation Phase:
(Starter (F-75) diet to promote the recovery of normal metabolic function and
nutrition-electrolytic balance. All children must be carefully monitored for signs of
overfeeding or over hydration in this phase. This phase lasts for 1-2 days)

2. Transition Phase:
(The transition phase is intended to ensure that the child is clinically stable and can
tolerate an increased energy and protein intake. Catch up diet (F-100) is given. This
phase lasts for next 2-4 days)
The child moves to the Transition Phase from Stabilization Phase when there is:
At least the beginning of loss of oedema
AND
Return of appetite
AND
No nasogastric tube, infusions, no severe medical problems
AND
Is alert and active

The ONLY difference in management of the child in transition phase is the change in type of diet. There is
gradual transition from Starter diet to Catch up diet (F 100).
The quantity of Catch up diet (F100) given is equal to the quantity of Starter diet given in stabilization
Phase.
3. Rehabilitation Phase:
Once children with SAM have recovered their appetite and received treatment for
medical complications they enter Rehabilitation Phase.
The aim is to promote rapid weight gain, stimulate emotional and physical
development and prepare the child for normal feeding at home.
The child progresses from Transition Phase to Rehabilitation Phase when:
1. S/he has reasonable appetite
2. Finishes > 90% of the feed that is given, without a significant pause
3. Major reduction or loss of oedema
4. No other medical problem
Feeding child with SAM
Cautious feeding in Stabilisation Phase
• Done with ‘Starter diet’ (F-75) until the child is stabilized. T
• To recover normal metabolic function and nutrition-electrolytic balance and but
there is NO weight gain.
• It is low in protein and sodium and high in carbohydrate, which is more easily
handled by the child and provides much-needed glucose.
• Contains 75 kcal and 0.9 g protein per 100 ml.
• 8-12 feeds over 24 hours are given (based on the body weight of the child).
• If the child has gross oedema, volume reduced to 100 ml/kg/day.
• If the child is eating 80% or less of the amount offered, nasogastric tube is used.
• 24-hour intake chart is maintained.
Catch up Diet in Transition &
Rehabilitation Phase
• Started to rebuild wasted tissues once the child is stabilised.
• Contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml.
• During this phase there is rapid weight gain.

Note: Children with SAM require Starter diet (also called F-75 diet) followed by catch-up diet (also
called F-100) for promotion of weight gain as well as functional and immunological recovery.
F-75 and F-100 refers to the specific combination of calories proteins, electrolytes and minerals that
should be delivered to children with SAM as per WHO guidelines made available for this purpose.
These diets can be prepared using locally available products
Starter Diet (F-75) and Catch up
Diet (F-100)
Discharge & Follow-up
• The average stay in a hospital setting varies between 10 to 15 days
(but can be longer), depending on each child’s medical recovery.
• However the child requires follow up for another 4-6 months for full
recovery, depending upon the child’s progress at home.
• Follow up is done in the community settings by the ASHA/ANM.

All SAM children should be followed up by health providers in the

program till s/he reaches weight-for-height of – 1SD.
Discharge Criteria
• Discharge criterion for all infants and children is 15 % weight gain and no signs of
illness.
• Oedema has resolved.
• Child is eating an adequate amount of nutritious food that the mother can
prepare at home.
• All infections and other medical complications have been treated.
• Child is provided with micronutrients Immunization is updated.
• Mother knows how to prepare appropriate foods and to feed the child.
• Follow-up plan is discussed and understood.
A malnourished
After treatment at NRC
child before
and Follow- ups
admission to NRC
Severely After treatment at NRC
malnourished and Follow- ups
child before
admission to NRC
THANK YOU