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ORIGINAL RESEARCH ARTICLE
“A PROSPECTIVE OBSERVATIONAL STUDY TO EVALUATE THE EFFICACY OF FACILITY BASED MANAGEMENT IN MALNOURISHED CHILDREN AT NRC, DISTRICT MEERUT.”
Rastogi S1, Maheshwari C2, Raghav SK3, Muzammil K4.

Authors Details:
Dr Swarna Rastogi1 MBBS, MD-PSM 1
Assistant Professor, Department Community Medicine, MMC Muzaffarnagar – 251203
Dr. Chaitanya Maheshwari2 (MBBS, MD-PSM) 2
Assistant Professor,Department Community Medicine, MMC Muzaffarnagar – 251203
Mr. Santosh Kr. Raghav ( M.sc.,M.Phil Statistics)3
Lecturer cum Statistician, Department Community Medicine, MMC Muzaffarnagar – 251203
Dr Khursheed Muzammil MBBS, MD-PSM 4
Professor and Head, Department Community Medicine, MMC Muzaffarnagar – 251203
WORD COUNT:
Abstract: 243 words
Main Article: 3804 words
CORRESPONDING AUTHOR:
Dr. SWARNA RASTOGI 1,
Assistant Professor, Deptt. of Community Medicine, Muzaffarnagar Medical College,
Muzaffarnagar (UP-251203); Mobile No: +91-9427346078; Email: [email protected]’ contributions:
Author No. 01- Instrumental in the conception and design of the study, acquisition of data, analysis of data and its interpretation.
Author No. 02- Responsible for drafting the article ; reviewing it critically for important intellectual content.

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Author No: 03- Performed the statistical analysis of the data for its significance.

Author No: 04- Supervised the whole research work and incorporated all the scientific and logical intellect and Helped in overall write-up ; thoroughly reviewed the final version for publication.

Acknowledgements: The authors are thankful to SIC district hospital meerut, Office Staff of NRC as well as PG’s of the Department of Community Medicine muzaffarnagar medical college for completion of this research project article.
Source of funding: Nil
Competing Interest: Nil
ORIGINAL RESEARCH ARTICLE
“A PROSPECTIVE OBSERVATIONAL STUDY TO EVALUATE THE EFFICACY OF FACILITY BASED MANAGEMENT IN MALNOURISHED CHILDREN AT NRC, DISTRICT MEERUT”
ABSTRACT
Background: Scarcity of suitable food, lack of purchasing power of the family as well as traditional beliefs and taboos about what the baby should eat, often lead to an insufficient balanced diet, resulting in malnutrition. In children, malnutrition is synonymous with growth failure. Malnourished children are shorter and weigh less than they should be for their age and height. Methods and Materials: The present study was conducted from September 2017 to November 2017,112 children aged 6-60 months who were admitted to NRC during the study period at district hospital Meerut were assessed. Checklist based on operational guidelines on facility based management was used. Data was analysed in Microsoft Excel and Epi info. Result: The study included 112 children in age group 6months to 60 months. There were 45 males and 67 females, out of which highest representation was from the age group of 13 to 24 months.7% of studied population belonged to general caste,24% OBC,67% SC and 2% ST. further results will be discussed at the time of presentation. Conclusion: Targeted supplementary nutrition and therapeutic nutrition with specific micronutrient to most vulnerable children for 14 days provided by Nutrition Rehabilitation Center can be helpful to improve nutritional status of young children. There is need to scale up community awareness and participation.

Keywords: malnutrition, Nutrition Rehabilitation center, awareness, under fives
Introduction
Reduction in child malnutrition is another MDG related to an improvement in child welfare. National data on underweight provided under NFHS-4 (National Family Health Survey) (2015-16) revealed underweight prevalence rate around 35.8%. In Meerut according to NFHS4, 35.2%, 18.8% and 35.3% of the children were underweight, wasted and stunted respectively.

Scarcity of suitable food, lack of purchasing power of the family as well as traditional beliefs and taboos about what the baby should eat, often lead to an insufficient balanced diet, resulting in malnutrition.

In children, malnutrition is synonymous with growth failure. Malnourished children are shorter and weigh less than they should be for their age and height.

The response to SAM in Uttar Pradesh is led by the National Rural Health Mission (NRHM). Currently, this response relies on a network of Nutrition Rehabilitation Centers (NRCs), where children with SAM receive therapeutic care following protocols the World Health Organization (WHO) 7 and the Indian Academy of Pediatrics (IAP) 8.
The objective of the analysis presented here is to assess the effectiveness of NRCs in providing therapeutic care for children with SAM in Uttar Pradesh and to inform the future design and implementation of programs for the provision of care for children with SAM in Uttar Pradesh and in India.

Objectives
To study 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 at the centers.
To find out knowledge, attitude and practices of mothers of the admitted children regarding the feeding practices followed at NRCs during their stay at the centers.

Facilities at Nutrition Rehabilitation center-
At the center 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 are brought to the centers by the AWWs. An incentive of Rs 50 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 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 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 severe malnourished 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 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. 50 per child is allocated/day during their stay at the centers and 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.

Materials and Methods
The present study was conducted at NRCs located at District Hospital, Meerut from September 2017to November 2017. The study was conducted on a sample size of 112 children aged between 0 and 60 months admitted to the NRC during the study period. The study design was prospective; wherein 112 children were recruited from the NRC to assess the nutritional status during the period of initial stay using anthropometric indicators on the admitted children recruited in the study at the NRCs. Initial recruitment of the children was done during the months of September 2017–november 2017. Weight at the time of admission and at the time of discharge and daily weight gain in g/kg were recorded and 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 recorded and the average duration of stay at the centers studied to establish any difference amongst the different age groups. A predesigned and pretested semi structured interview schedule was used to interview the mothers of the admitted children on awareness regarding government programmes focusing on nutrition, basic concepts of nutrition, etiologies of malnutrition, and the preparation of 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, ?2 test, and ANOVA were applied wherever needed.

Results:
AGE IN
MONTHS MALE
(N =45) FEMALE
(N=67) TOTAL
(N=112)
NO (%) NO (%) NO (%)
7 – 12 20 (44.4%) 26 (38.8%) 46 (41.1%)
13-24 08 (17.7%) 19 (28.3%) 27 (24.1%)
25-36 03 (6.7%) 05 (7.5%) 0 8 (7.1%)
37-48 02 (4.5%) 12 (17.9%) 14 (12.5%)
49-60 12 (26.7%) 05 (7.5%) 17 (15.2%)
TOTAL  45 (100.0%) 67 (100.0%) 112 (100%)
Sociodemographic profile of participants
The study group included 45 males and 67females. 41.1% of the children were in the age group of 7-12 months (20 males and 26 females) followed by 24.1% in the age group of 13-24 months (8 males and 19 females). 67% of the study population belonged to the scheduled caste (SC) group and 24% to the other backward
class (OBC), 7% in general and 2% in scheduled tribes (ST). 70% of the admitted children were APL (Above poverty line) and 30 % were BPL( below poverty line). 56% of the admitted children were referred by OPD/CMTC/MO, 34% by AWW and 10% by ASHA workers.

Effect on selected anthropometric Indicators (weight, height and MUAC) of the admitted children during their stay at the NRCs
Analysis of the admitted children based on weight
A total of 112 children were included in the analysis: 45 (40.18%) males and 67 (59.82%) females were analyzed for effect of nutritional interventional measures on anthropometric indicators.

AGE IN
MONTHS MEAN OF WEIGHT
KG± SD PAIRED t TEST
ON ADMISSION ON DISCHARGE 7 to 12 5.65±1.90 6.26±2.00 P;0.05(S)
13 to 24 6.29±2.40 6.83±2.52 P;0.05(S)
25 to 36 8.08±1.22 9.05±1.39 P;0.01(S)
37 to 48 9.57±2.31 10.2±0.98 P;0.05(S)
49 to 60 12.7±3.01 13.4±2.86 P;0.01(S)
The overall mean weight at the time of admission for these children was 8.458 ± 3.11 kg and 9.15 ± 2.14 at the time of discharge. A statistically significant difference was observed between the mean weights at discharge and the mean weight at admission for the study group. (P;0.05(S)Table 2.

The overall average weight gain for the study group during their stay at the center was 9.92 ± 5.43 g/kg/day; the average weight gain being 8.79 ± 5.30g/kg/day for males and 11.04 ± 5.39 g/kg/day for females. An average weight gain of at least 8 g/kg/day is considered to be adequate for a child during stay at the nutritional rehabilitation centers.

TABLE 4: EFFECT ON WEIGHT FOR HEIGHT (W/H) Z SCORE
W/H (Z SCORE) NUMBER OF CHILDREN
ON ADMISSION ON DISCHARGE
SEVERE ACUTE MALNUTRITION ?3 SD 96
(85.71%) 43
(38.39%)
MODERATE ACUTE MALNUTRITION
?3SD TO ?2SD 16
(14.29%) 69
(61.61%)
TOTAL 112(100%) 112(100%)
?2= 53.2557, P;0.00001(HS)
At the time of admission, 96 (85.71%) children were severely malnourished (z score ?3SD), while 16 (14.29%) children suffered from moderate or mild malnutrition (z score ? 3SD to ?2 SD).(7) 43 (38.39%) children were
still severely malnourished (z score ?3SD), while 69 (61.61%) children were suffering from moderate or mild malnutrition (z score ? 3SD to ?2 SD) at discharge. 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 (?2=53.2557, P;0.001) Table 4.

Table 3: EFFECT ON MUAC (MID UPPER ARM CIRCUMFERENCE)
MUAC (CM) NUMBER OF CHILDREN (%)
ON ADMISSION ON DISCHARGE
SEVERE ACUTE MALNUTRITION ;11.5 76
(67.86%) 38
(33.93%)
MODERATE ACUTE MALNUTRITION
11.5 TO ;12.5 30
(26.78%) 55
(49.11%)
NORMAL ;12.5 06
(5.36%)
19
(16.96%)
TOTAL 112(100%) 112(100%)
?2=26.7796, P;0.0001 (HS)
Analysis of the admitted children based on MUAC
MUAC data were analyzed for 112 children. At the time of admission, 76 (67.86%) children were severely malnourished (MUAC ;11.5 cm), while 30 (26.78%) children suffered from moderate or mild malnutrition (MUAC 11.5 cm to ;12.5 cm) and 6(5.36%) ere normal (MUAC;12.5 cm).38 (33.93%) children were still severely malnourished (MUAC ;11.5 cm), while 55 (49.11%) children were suffering from moderate or mild malnutrition (MUAC 11.5 cm to ;12.5 cm) and 19(16.96%) were normal at the time of discharge. 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 (?2=26.7796, P;0.001)
Duration of stay at the NRCs
The average duration of stay at the NRCs was 12.01 ± 1.61 days, for male children it was 13.73 ± 1.89 days and for female children it was 10.23 ± 1.30 days. Statistically significant difference was observed among the different age groups with respect to duration of stay at the centers (p;0.005).

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