|Year : 2014 | Volume
| Issue : 1 | Page : 22-26
Nutritional rehabilitation using energy dense local food as ready to use therapeutic food in hospitalized malnourished children: Case for primary prevention at grass root levels
Sandeep Sachdeva1, Mona Vijayaran2
1 Department of Community Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
2 Department of Pediatrics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||15-May-2014|
Dr. Sandeep Sachdeva
3/115 A, Durgabadi, Marris Road, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Children and toddlers are highest risks of falling prey to malnutrition. Locally indeginous calorie and protein rich supervised supplementation is a promising endeavour towards childhood growth emancipation.
Objective: To assess the impact of nutritional rehabilitation using energy dense local food as Ready to Use Therapeutic Food (RUTF) among malnourished hospitalised children.
Methodology: One hundred and twenty five hospitalised malnourished children (Grade III and IV PEM, Protein Energy Malnutrition (as per the Indian Academy of Pediatrics, IAP guidelines) in the age group 6-60 months were included in the study. Their prevalent feeding practices were recorded. They were divided into three groups - Group A (given Family diet only), Group B (given Family diet + RUTF) and Group C (given Family diet + RUTF + Multivitamin preparation containing zincovit drops 5 drops per serving). Their weight, height, Mid Upper Arm Circumference (MUAC), haemoglobin levels and Serum albumin were monitored for 2 months.
Results: Lack of early initiation of breastfeeding (66%), giving prelacteal feeds (61.0%), lack of exclusive breastfeeding (83.4%) and non initiation of complementary feeding at 6 months (60%) are the prevalent IYCF practices. Nutritional rehabilitation with Family diet alone (Group A) was less effective in contrast with family diet + RUTF (Group B) and Family diet + RUTF + Multivitamin (Group C). Addition of multivitamin (Group C) to RUTF (Group B) failed to exhibit added nutritional benefits.
Conclusion: Prevalent IYCF practices were far from optimum compared with the recommended guidelines. RUTF from the locally available foods is cheap and effective in combating malnutrition effectively. Addition of multivitamins showed no benefit. RUTF prepared from locally available food for nutrirional rehabilitation malnourished children is recommended.
Keywords: Energy dense food, infant and young child feeding, nutritional rehabilitation, ready to use therapeutic food
|How to cite this article:|
Sachdeva S, Vijayaran M. Nutritional rehabilitation using energy dense local food as ready to use therapeutic food in hospitalized malnourished children: Case for primary prevention at grass root levels. J Med Trop 2014;16:22-6
|How to cite this URL:|
Sachdeva S, Vijayaran M. Nutritional rehabilitation using energy dense local food as ready to use therapeutic food in hospitalized malnourished children: Case for primary prevention at grass root levels. J Med Trop [serial online] 2014 [cited 2020 Jan 19];16:22-6. Available from: http://www.jmedtropics.org/text.asp?2014/16/1/22/132573
| Introduction|| |
Worldwide, 10.9 million children under five years of age die every year due to malnutrition, of which 2.42 million deaths occur in India alone. Two-thirds of these deaths (1.6 million) occur during the first year and are related to inappropriate infant and young child feeding practices. 
The National Family Health Survey-3 (2005-06) estimates that 8 million under-five children in India are suffering from severe acute malnutrition (SAM).  The World Health Organisation (WHO 2006) estimates that 53 percent of pneumonia and 55 percent of diarrhoea deaths are attributable to poor feeding practices during the first six months of life. 
Ready-to-Use-Therapeutic Food (RUTF) has been recommended by the WHO as their results have been rewarding and they can be given at home. However, they should be produced locally by each country, keeping in view the International Standards. ,, The WHO F100 and RUTF apart from being expensive are not available everywhere. The home based RUTF uses nutrient dense locally available food and has the distinct advantages in terms of cost, logistics of procurement, distribution, and sustainability. 
For the study we developed a RUTF from locally available food named as 'RUTF Agra 'using following the ingredients as indicated in [Table 1]. There is a paucity of studies using RUTF in Indian settings and using RUTF prepared from locally available food items. Hence this study was undertaken.
| Methodology|| |
This hospital based interventional study was conducted in the Department of Paediatrics, S. N. Medical College, Agra from January 2011 to September 2012. Children (n = 125) suffering from Grade III and IV PEM in the age group of 6 months to 60 months, and otherwise not concurrently suffering from an acute illness were enrolled in the study. Children with altered sensorium, clinical suspicion/confirmation of congenital heart disease, malignancy, known metabolic disorders and documented chronic illnesses e.g. Tuberculosis, Nephrotic syndrome and proven HIV cases were excluded from the study. The aims and methods of the study were approved by the Instititional Ethical Committee of the BR Ambedkar University, Agra and adequate informed and written consent were taken from eligible parents and/or guardians with the aims and objectives appropriately explained to them. Only those children were included wherein the parents/wards and eligible children consented and assented to the same.
- The detailed feeding habits of the children at the time of enrollment were recorded in a predesigned, pretested, semi structured proforma
- Nutritional intervention
Malnutrition was graded according to the IAP classification. For nutritional rehabilitation, they were grouped into three: Group A (n = 34) received family diet alone, Group B (n = 46) received Family diet + RUTF and Group C (n = 45) received Family diet + RUTF + Multivitamin.
The researcher along with the Medical Officer of the Malnutrition Clinic in the Pediatrics Department at our centre were responsible for education regarding prepararion, storage and feeding at periodic aliquots as decided by the age, weight of the child and his grade of malnutrition. Diets using different proportions of the Agra RUTF were obviously costomised for individual children. Also, the trainers demonstrated the preparation of the RUTF Agra in the presence of mothers, and preferably fathers as well as part of a two day workshop, which used to be repeated at periodic intervals when a sufficient sample of new eligible children would accumulate. Periodic post test sessions were also performed by the researchers with mothers/caregivers as trainees/examinees. Discreipancies were dealt with, and preparing custom diets for different children, storage, importance of hygiene were indispensable ingredients of the training sessions. The palatibity, hygiene and taste of the RUTF were personally checked by the author and/or mothers/medical officer of the malnutrition clinic. Only when the RUTF was pretested and tretasted, was the same offered to children. There was no use of force or coercion, or any untoward event.
Mothers were counselled regarding the optimal family diet according to the IMNCI guidelines.  RUTF was prepared from locally available food (we named it as RUTF Agra. It was prepared by mixing and grinding 25 g each of jaggery, peanut, puffed rice and bengal gram to make a total of 100 gm. During hospitalization, children of Group B and C were given 1 pack containing 50 gram of RUTF per day. Next day, it was ensured that the child had consumed full RUTF given on the previous day. Upon discharge, these children were given 7 packs of RUTF (sufficient for a week) and were asked to visit for follow up on a weekly basis. Caretakers watched demonstration and were advised to give 50 gram of this RUTF per day in 3 or more aliquots as dry powder or by making a paste with water or milk. Children of Group C also received multivitamins (2 × Recommended Daily Allowances, RDA). In this regard, the authors would like to concur that multivitamins were added with an intent to seek for their probable effect on minimising oxidant effect of micronutrients, which would otherwise manifest with edema, poor feed intolerance and heart failure in extreme cases when nutritional rehabilitation is started. Weight, Height, MUAC, Haemoglobin levels and S. albumin levels were assessed at baseline and on Day 60 of follow up.
Data collected was analysed using SPSS version 19. (SPSS, Chicago, IL). Continuous variables were expressed as mean ± standard deviation (Gaussian distribution) or range and qualitative data was expressed as percentage. Chi square test and Fisher's exact test were used for univariateanalysis. All P values were two tailed and values of < 0.05 were considered to indicate statistical significance. All confidence intervals were calculated at 95% level.
| Results|| |
A total of 125 children were enrolled; 57 males and 68 females. Good IYCF practices observed in the study group were - (a) Initiation of breastfeed within one hour of birth (33.3%), (b) giving colostrum (70.4%), (c) not giving prelacteal feed (38.4%), (d) exclusive breastfeeding till 6 months (16.6%) (e) initiation of complementary feeding at the recommended time (39.4%), (f) minimum dietary diversity (18.9%), and (g) minimum meal frequency (46.7%) [Table 2].
Out of the 125 enrolled cases, 15 children were lost to follow and remained so till day 60s days of follow up, as they had changed their mind on their prior commitment for the study and were reported to have sought medical advice from local prectitioners when the authors contacted them on phone. The reasons cited were their faith in traditional medicines from local quacks, child developing acute illness and no male in the house to ferry them to the hospital, etc. The data of 110 children (30 in Group A, 40 in Group B and 40 in Group C) were analysed. During 60 days of nutritional rehabilitation; the following parameters were measured, viz. weight gain, height gain, MUAC gain and rise in level of hemoglobin, The rate in change in growth velocity by subtracting the current weights and lengths/heights minus the the prior reading, all divided by the initial reading. A rise was observed in all the three groups. The rate of weight gain was almost 4 to 5 times more in Group B and C c.f Group A (P ≤ 0.001) and the rate of gain in height and MUAC were almost double in Group B and C c.f Group A (P ≤ 0.05) [Table 3]. The rate of gain in weight, height and MUAC in Group B c.f Group C was not statistically significant ( P ≥ 0.05).
|Table 3: Growth rate in weight, height and MUAC during 60 days of nutritional rehabilitation|
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The rise in hemoglobin level in Group B and C c.f Group A was almost 3 to 4 times more but on comparing the rise in hemoglobin level between Group B and C, no statistical significance was observed ( P ≥ 0.05) [Table 4].[Table 5] depicts the various formulations for nutritional rehabilitation of malnourished children for comparison. The ingredients are largely common but vary in proportions whereas the CMC, Vellore RUTF and WHO RUTF were comparable at providing 550 kcal/100g, the RUTF prepared at Agra provided 370 kcal/100g.
|Table 4: Change in blood hemoglobin and S albumin status of children after two months of nutritional rehabilitation|
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|Table 5: Comparison of various formulations for nutritional rehabilitation of malnourished children|
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| Discussion|| |
The XI five year plan drafted by the Planning Commission of India has focussed on the realisation of the Millenium Development Goals (MDG) and Targets laid down by the WHO, particularly the MDG 4 Goal 4, which addresses the child malnutrition components and mortality respectively; ,, envisaged at early initiation of breastfeeding 50%, exclusive breastfeeding till 6 months (80%) and timely introduction of age-appropriate complementary feeding (75%). The National figures lag behind these targets. The National (NFHS-3) and U.P State figures for 2005-06 for early initiation of breastfeeding were 24.5% and 33.3%, for exclusive breastfeeding were 46.4% and 16.6% and for timely initiation of complementary feeding were 53% and 39.4% respectively.  The respective figures in the present study were far too grim, being 33.3%, 16.6% and 39.4%. respectively.
The WHO consensus meeting on Infant and Young Child Feeding, IYCF held at Washington DC (2007) has added two parameters for IYCF practices assessment. One is minimum meal frequency which is 2 times for breastfed infants 6-8.9 months, 3 times for breastfed children 9 -23.9 months and 4 times for non-breastfed children 6-23.9 months. The other parameter is minimum dietary diversity i.e., a child should receive food from ≥4 food groups out of the 7 recommended groups: (i) Grains, roots and tubers, (ii) legumes and nuts, (iii) dairy products (milk, yogurt, cheese), (iv) flesh foods (meat, fish, poultry and liver/organ meats), (v) eggs, (vi) vitamin-A rich fruits and vegetables and (vii) other fruits and vegetables. , Minimum meal frequency and minimum dietary diversity reported in NFHS-3 is 41.5% and 21% respectively.  In the present study, the respective figures were 46.7% and 18.9%.
The WHO has also recommended RUTF for the management of 'Severe Acute Malnutrition' but these formulations are expensive, not easily available and are not affordable in the Indian context. ,,,, Attempts have been made to prepare RUTF using locally available food in India with good results. , The Agra RUTF used in the present study has shown good results in terms of weight, height, MUAC gain along with rise in serum haemoglobin level. Addition of multivitamin increases the cost but has not been found to be beneficial upon comparing it with RUTF alone. The caloric value can be enhanced by adding oil/milk powder but with disadvantage of increased cost, problems of preservation, reconstitution, palatability and acceptability.
| Conclusion|| |
Prevalent child feeding practices in the community are far from optimum. In all efforts to combat malnutrition, economic constraints always play a great role. RUTF from the locally available foods are a cheap and effective option in treating and preventing malnutrition. Home diet alone is not an effective solution. Addition of multivitamins etc., was hardly of any benefit, perhaps because they are meant to complement rather than supplement primary nutrients. There is a need to educate the caretakers and health care professionals for these optimum feeding practices and RUTF prepared from locally available cheap foods, can be a boon to children with Gd 111 and 1V malnutrition without a concurrent infectious/other complications. This further adds case to the widely recommended domiciliary management of such children. It would be worthwhile to recommend in the near future, the incorporation of maternal training and ultimate incorporation of 'customed' RUTF into the diet of particularly'at risk' malnourished children. Further research is warranted on the development and breeding of local inexpensive 'staples' to account for the vast diversity of food stuffs consumed in India.
| Acknowledgements|| |
The authors are indebted to Prof. NC Prajapati, Dr. Rahul Pengoria from the Dept of Pediatrics, SN Medical college, Agra and Dr. S. Singh from the Dept of Obs and Gynae, SN Medical college, Agra for their valuable contributions, without which the study would not have been possible.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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