Management of Severe Acute Malnutrition in Madhya Pradesh – Present Status 2006 - 2010

1. Management of Severe Acute Malnutrition in Madhya Pradesh – Present Status 2006 - 2010 Dr. Manohar Agnani, M.B;B.S MIH Mission Director, NRHM DPHFW, GoMP

2. Enormity as per NFHS-III 1.26 million children under 5 years in MP are severely wasted

3. Bal Shakti Yojna • Biggest SAM management program in the country • Initiated in 2006 • Planned and funded under NRHM • Technical and Strategic support from UNICEF • Facility Based Care model for management of all SAM children

4. Due care of Adolescent girls and maternal nutrition to help shape the baby’s tomorrow Early initiation of Breast feeding Promotion of Exclusive breast feeding up to first 6 months Improved access to locally available low cost nutritive foods Ensuring availability of micronutrients – Zinc, Vitamin A, IFA, Iodine Emphasis on early identification & treatment of severe acute malnutrition (SAM) Evidence based interventions to address under nutrition

5. The First Step - 2006 NRC conceptualized and set up in Shivpuri district in January 2006 IAP guidelines adapted Admission criteria - W/A (Grade III & IV) Locally made F-75 & F-100, and mixed Diets Mothers counseled Discharged from NRC after 14 days Regular Follow ups ensured

6. NRC Strengthened - 2007 47 NRCs established till mid 2007 across the State IAP 2006 guidelines followed Appropriate infrastructure and Staff recruitment Revised administrative guidelines implemented Treatment cost – Rs. 3375/Child AWWs to refer SAM children to NRC Residential Trainings of NRC Support Staff started Standardized preparations as per IAP of F-75 & F-100 taught MUAC & W/H measurement introduced but admission criteria was W/A Support ensured by UNICEF - W/H wall charts, MUAC tapes Recording system streamlined

7. Scaling up NRCs - 2008 More than 100 NRCs functional by 2008 Looking at the magnitude of the problem, NRCs planned in every high risk block Diet charts formulated based on weight range

8. Way Forward in – 2009 • 196 NRCs functional • Appetite test formulated and standardized with local available food • Feeding protocol • Locally made F-75 and F-100 as per IAP/WHO protocol along with mixed feeding • Admission criteria • W/L <–3z score &/or • MUAC <11.5cm &/or • Bilateral Oedema • Follow-up after discharge • 4 Follow ups at 15 days intervals for 2 months • Appropriate MIS system

9. Present NRC Scenario – 2010 • 210 NRCs functional • Rs. 3500 /- per child, treatment cost • Feeding protocol • Locally made Therapeutic Feed introduced across the State • Discharge criteria from Program • 15% weight gain over the Admission weight • Introduction of Multi-charts for recording feeding and treatment of SAM child • Supplementary suckling technique (SST) unit in NRC for management of <6m SAM child

10. Human Resource at NRC

11. Current Strategy for the Management of SAM and Severely Underweight

12. Ten Steps for Management of Severe Acute Malnutrition at NRCs

13. SCREENING at NRC TRIAGE APPETITE TEST Direct admission to Phase 2 in NRC: pass appetite test and no complication Direct admission to Phase 1 in NRC: Fail appetite testor complication Fails appetite test or develops medical complications Phase 1 In-patient treatment F 75 Phase 2 treatment in NRC using F100/ TF/mixed DIET based on protein and calories recmnd in IAP 2006 Loss of appetite and increase in edema Return of appetite and reduction of edema Transition Phase In-patient treatment F100/TF Good appetite: no edema Good appetite: no edema DISCHARGE Community Care & Follow up by AWW (SFP) 4 FOLLOW UP AT 15 DAYS INTERVAL AT NRC

14. Financial Guideline for Bal Shakti Yojna NRHM Fund Running cost (including Follow up) Establishment Cost • Rs. 200/- (100+100) for transportation to Mother • and 100/- Incentive to AWW / Child Rs. 1,35,000/- per NRC • Wage loss compensation to mother 65 Rs / • Day Rs. 25 / day to be spent on child’s food Cots, Heat Convector, Blankets, Refrigerator, Mixer, Water Purifier, kitchen materials, ward materials, weighing machines, growth charts etc. • Staff salary & infrastructure 4 Follow Ups of each child (Wage loss compensation, AWW incentive & transportation cost) • Total cost per • child Rs. 3500 /-

15. SAM Children treated in NRCs

16. Field Challenges – 56% Bed occupancy despite fully functional NRCs in high risk blocks Reluctance of mothers to come to NRCs in spite of intense counseling by field workers Migration of family due to their work, poses a setback in tracking the child Seasonal work opportunities leading to delay & reluctance in admissions Responsibility of other siblings/household members on mother, restricts her stay in NRC with her SAM child Severe underweight child not falling into SAM admission criteria not admitted in NRC – leading to De-motivation in Community

17. Every day, on average more than 26,000 children under the age of five die around the world, mostly from preventable causes. Nearly all of them live in the developing world.

18. Thank You….. Thy didn’t know what to do with that. Thy sent high-calorie food, granola bars to feed kids. But it did not fight Severe Malnutrition