Managing malnutrition: Emergency Ward and
Nutrition Rehabilitation Centre, West Bengal, India
March 2008-February 2009
CINI’s Emergency Ward and Nutrition Rehabilitation Centre’s aim is to not only relieve the suffering of seriously malnourished children in West Bengal, India, but to protect their future welfare by working closely with families to help prevent malnutrition from occurring again. The Emergency Ward provides emergency health care treatment to children with acute malnutrition and related health problems, and the Nutrition Rehabilitation Centre rehabilitates undernourished children whilst also providing supportive care and training on nutrition and preventative healthcare to their carers (usually their mothers).
Objectives are to help the children admitted
To gain weight at a normal or increased rate;
To ensure the children’s appetite has returned, and that they are eating a balanced diet that can be prepared by the mothers in the home environment;
To train the mother about nutrition and preventative healthcare practices, and to be sure she feels confident about being able to look after her child before being discharged;
To ensure the mother knows about the home treatment of diarrhoea, fever and acute respiratory infections;
To control secondary infections;
To monitor when developmental milestones are reached;
To undertake regular follow-up on the health of the child and mother, where possible, thereby developing a good relationship between the family and CINI’s health workers;
To encourage mothers to share what they have learned to other mothers in their community.
Progress
More than 27,000 children per year are brought to CINI’s outpatient clinics in Pailan. The clinic’s services include growth monitoring, health checks, immunisation and health and nutrition education. The most serious cases of malnutrition or illness are admitted to the Emergency Ward or Nutrition Rehabilitation Centre. Seriously ill children, where the major cause is not nutrition related, are referred to a local government hospital for treatment.
CINI helped 575 children (295 male and 280 female) and their mothers at its Emergency Ward and Nutrition Rehabilitation Centre between March 2008 and February 2009. 72% of children got rid of secondary infections, gained weight and normal appetite returned. The remaining 28% did not show weight gain but were discharged with a change in feeding and hygiene habits, or were referred to a local hospital for the treatment of complications. Assessment for discharge is based on the confidence level of carers, rather than the weight gain of the child, as this is the key to ensuring sustained recovery.
Baby Hasina, 7 months 2.9kg (6.4lbs) 1 April 2008
Hasina less than 4 weeks later 3.7kg (8.2 lbs)
Children are between a few days and six years old on admission. Common problems include: growth faltering, manifestations of malnutrition, feeding problems, diarrhoea, dehydration, skin infections, and acute respiratory tract infections. Many are at risk of disabilities such as blindness, deafness and learning difficulties, as well as chronic diseases, through lack of vital nutrients during their development.
575 mothers were also admitted for residential care and support. They received hands-on training on nutrition, preventative health care, and child rearing practices during their stay. CINI’s Lactation Management Unit supported mothers who were having problems breastfeeding to relactate.
Over the year we held counselling sessions with the fathers of all 575 patients, and 376 paternal grandmothers, as their support was important to prevent a crisis in the child’s health from reoccurring. Indirectly, the siblings (estimate 2,300) and neighbouring households (estimate 4,600) of the children admitted will benefit from the training of their mothers or aunties.
The Emergency Ward
306 of the 575 children were admitted onto the 10-bed unit ward over the year. The ward provided emergency care facilities to children with acute malnutrition-related health problems including hypoglycaemia, hypothermia, pneumonia, severe dehydration, chronic diarrhoea, severe anaemia, micronutrient deficiencies and electrolyte imbalances. Ill and severely malnourished babies and children were nursed here until they were strong enough to join their mothers in the Nutrition Rehabilitation Centre.
Feeding is one of the crucial components of managing moderate and severe malnutrition. The dictum is, ‘go slow’ and avoid ‘force feeding’. If the feeding begins too aggressively or the child is given a diet rich in protein or sodium, there are chances of overwhelming the child’s system which can be fatal.
Nutrition Rehabilitation Centre
269 of the 575 children were admitted onto the centre’s 12-bed unit over the year. The centre is used for rehabilitation of undernourished children plus supportive care and capacity building of mothers. Each mother was provided with accommodation, food and emotional support as her child was nursed back to health. Health workers provided training on health and hygiene, breast feeding and complementary feeding, home management of diarrhoea, plus growth monitoring and promotion. Parents were also informed about the value of primary immunisation.
Activities
Nutrition Demonstration: 44 hands-on demonstrations were held to train mothers and empower them with practical knowledge about nutrition.
Health education sessions: 70 sessions were conducted to educate mothers about health, nutrition and care to sustain their child’s health.
Role-play: 2 role-play sessions were conducted to help mothers identify with model behaviour, helping them relate and improve their learning.
Follow-up home visits: 15 visits were conducted by a health worker (often accompanied by a doctor or nutritionist) on a monthly basis to ascertain whether mothers have put into practice what they learnt once discharged. The main aim of these visits was to ensure that the child was growing and gaining weight properly, to find out if there were any health concerns, and to make sure the child had been immunised. Each child was given medical record card in which the weight of the child is monitored on a growth chart and where all immunisations are recorded.
Liaison with community-based workers: Liaison with community workers is important as they work at the grassroots and are the nearest to the community.
Voluntary follow-up at clinics: 85% of children previously admitted received follow-up service. 63% came to CINI for follow-up, and 22% were followed-up by CINI’s health workers at home. The remaining 15% had a poor follow-up because they either lived far away from the clinic, the families were unable to spare one day’s earnings to attend the follow-up clinic, the follow-up took place at a local hospital, or because there was a lack of family support for the child’s health and nutrition. Of the children who did receive follow-up, 71% showed steady weight gain, 15% had recurrent illnesses due to poor hygiene, sanitation and a lack of child care (usually as a result of the large family size), and 14% had to be readmitted to the clinic. The main reason for readmission tended to be a result of the lack of cooperation from family members, the poor economic status of the household and the large family size.
Celebration of events: Children’s Day was celebrated. Activities included a quiz and a baby show. For the quiz, caregivers were asked questions about breast milk, supplementary food, common childhood illnesses, immunisation and hygiene. This helped assess the knowledge level of the mothers and enabled them to recapitulate information. Children aged 6 months to 3 years participated in a baby show. Performance was measured on the basis of the infant’s hygiene, nutrition, immunisation status and the level of their mother’s knowledge. This event provided the opportunity for mothers and children to gather a healthy social environment and was an entertaining forum to learn about good health practices. It gave mothers more confidence, and was a welcomed change to the daily routine of rehabilitation.
Working alongside the government
The government hospital services are ill-equipped to deal with the underlying problem of malnutrition, which is more than a medical problem. It usually requires several weeks to bring about a sustainable improvement in the nutrition status of a severely malnourished child. As a result, CINI links up with the local Gram Panchayat (local self government) to help the most economically disadvantaged families secure future income. It also seeks the support of the Gram Panchayat or community institutions in order to address social issues.
Training of government staff
As experts on treating and preventing malnutrition, our work is being used to train government staff on best practice. 1,150 government health workers received this training. Initially, training focused on improving the knowledge of accredited self-help activists, who work at the grassroots level to coordinate health and nutrition initiatives in the community. Building the capacity of government workers has become a priority. Each month 20 to 50 government health workers are trained on community-based management of malnutrition.
Major challenges faced
Tracking children who received poor or no follow-up
Changing the behaviour of the family members regarding child care practices
Managing the malnutrition of children with limited resources
Providing economic security for the family which is important for the nutrition of the child.
Key lessons learned
Involving local self government community members is important for the sustainable improvement of the health and nutrition of the children
Joint counselling sessions for parents is crucial for the child’s rehabilitation.
Learning to breastfeed
Neel was admitted to the Nutrition Rehabilitation Centre at CINI with his mother, Maitun, at two months of age. He weighed just 3.6kg (7.9 lbs) and had been losing weight steadily. Maitun began breastfeeding her son from his first day of life, but after 15 days her mother-in-law decided that Maitun had insufficient milk to feed Neel, and should therefore start using milk substitutes in addition to her breast milk. Neel was fed a diet of breast milk and wheat flour mixed with cow’s milk, sugar and water. Maitun found breastfeeding Neel increasingly difficult, and eventually found she was unable to provide any milk for her child.
Following Maitun’s admission she was given advice on how to get the milk flowing again. CINI health care workers spent time with her, providing explanations of the technique and timings of breastfeeding, as well as giving her physical and emotional support. Maitun told a volunteer at the clinic that her confidence had greatly improved in just one week. She said CINI had helped her greatly, and she now felt that she had a lot of milk, and that her son was feeding well. Neel sleeps comfortably in his mother’s arms
The World Health Organisation advises that infants should be exclusively breastfed for the first six months of life, especially in developing countries. Children who are fed formula feed are at risk of infection, as the water used to make up the formula may not be clean, and it is difficult to sterilise feeding bottles. In addition, parents often try to make expensive formula milk last longer by using a packet sufficient for only one month over three months. CINI therefore works hard to promote breastfeeding and provides support and advice to mothers on feeding practices.
Neel sleeps comfortably in his mother’s arms
Follow-up visits: maintaining good progress
At only 5 months old Arup had a bad episode of gastroenteritis, and as a result, his weight dropped. Thanks to his mother’s vigilance and his medical records, CINI’s health workers were able to quickly identify that he had developed Grade II malnutrition.
Deeti and Arup were admitted to the Nutrition Rehabilitation Centre for three weeks, and Arup’s weight was stabilised with the help of his mother and staff at the centre.
Deeti and her 8 month old son, Arup are now back at home and are both well. The health workers are very happy with the progress of Arup’s growth, and feel that he is developing into a healthy, strong child.
Arup examines his medical card whilst in his mother’s care
