Nutritional rehabilitation of infants < 6 months with severe acute malnutrition

Summary of published research¹

Location: India

What we know: There is a significant burden of acute malnutrition in infants under 6 months of age in nutritionally vulnerable countries. There is a lack of guidance on management of this caseload and a lack of evidence to inform guidance development. Most studies and programme descriptions are on children over 6 months of age.

What this study adds:This study describes the feeding and clinical profiles, management strategies and outcomes of infants < 6 months managed in a Nutrition Rehabilitation Centre in India. Death rates were low (2.9%). Non-responders were high (26.8%) due to caregiver refusal to stay in hospital for treatment. Nearly half of cases (45%) were not breastfed on admission. The most common presenting symptom was acute diarrhoea. Withholding intravenous fluids, early initiation of feeds and staff trained on breastfeeding problems and management were key to success.

Most of the studies on severe acute malnutrition (SAM) have been on children between 6 months and 59 months of age. A recent study was conducted to determine the outcome in infants < 6 months of age with SAM, admitted to Nutritional Rehabilitation Centres (NRC) after nutritional rehabilitation. Management was based on the guidelines issued by the Ministry of Health and Family Welfare (MOHFW) in India in collaboration with WHO.²

The records of all infants < 6 months admitted in the NRC over a period of 20 months (January 2011 through August 2012) were collected and analysed. The criteria for admission of these infants were weight for length (W/L) < −3 standard deviation (SD) (if length>49 cm) or visible severe wasting or oedema both feet. The infants were admitted, managed and discharged according to the set guidelines issued by the MOHFW.

Nurses, dieticians and the cooks were specially trained in identifying children with SAM and nutritional rehabilitation protocols. Supplementary suckling techniques (SST) were applied to mothers with lactation failure. Until breastfeeding was fully established, the infants were started on non-cereal based therapeutic diet, F100-diluted (F100 D) feeds.

The infant was weighed daily using a SECA digital weighing scale (precision 5g) in the morning at a fixed time before feeds. When the infant had gained weight for five consecutive days at the centre and was free from any medical complications, he/she was fit for discharge. Non breast-fed infants were discharged on locally available animal milk with cup and spoon. The infants were called for four follow ups at two weekly intervals. The outcome indicators were: i) Cured: infants meeting the discharge criteria, ii) Non-responders: infants not responding to the treatment and nutritional rehabilitation during hospital stay, iii) Relapse: infant who has been discharged as cured from the hospital within the last two months but is again eligible for admission, and iv) Death.

A total of 431 children with SAM were admitted in the NRC during the period of 20 months. Of these, 108 (25%) children were < 6 months of age. The average weight gain of the infants during hospital stay was 12±9.73 g/kg/d. Forty-seven (43.5%) infants were < 2 months of age, 43 (39.8%) infants were 2–4 months and 18 (16.7%) infants were > 4-< 6 months of age. The average weight gain during hospital stay in these age groups was 15.9g±10.7, 10.7g±7.8 and 10.4±9.1 g/kg/d respectively. This difference in weight gain was found to be significantly different (p =0.01).

Outcome indicators are given in Table 1. Overall, 63.8% infants < 2 months of age were successfully discharged on exclusive breastfeeding with good weight gain against 46.5% in age group of 2–4 months and 56.2% in infants > 4-<6 months. Out of 108 infants < 6 months, 59 (54.6 %) were being breastfed at the time of admission, of whom only two infants were being exclusively breastfed. Forty nine (45.4%) infants were not being breastfed at all. Ninety babies (83.3%) had one or more medical complications at admission and were first stabilised in the emergency ward before transfer to the NRC; only 18 (16.7%) infants were directly admitted to the NRC. The most common presenting symptom was acute diarrhoea (35.2%) followed by failure to gain weight (26.9%). The Supplementary Sucking Technique (SST) was used in 44 (40.7 %) infants; it was successful in 32 (72.7 %) infants and failed in 12 (27.3 %) cases. Of those infants cured, 20 infants (27%) were managed by correction of breastfeeding positioning and attachment alone.

Withholding intravenous fluids and early initiation of feeds are key to the management of children with SAM and diarrhoea. The daily weight gain chart was a good motivating factor which even the illiterate mothers were able to understand. The study authors were able to achieve good weight gain in almost half of the babies on breastfeeding alone after counselling. Just over one quarter of infants (26.8%) were non responders; the main reason being that the parents were not willing to stay in the hospital for sufficient time for nutritional rehabilitation.

A limitation of the study was that it was not possible to achieve a good follow up and therefore observe how the infants fared after discharge. The study authors conclude that although most of the mothers were aware that breastmilk is the best food for their babies, many were unable to cope with the challenges of exclusive breastfeeding, such as misconceptions about producing insufficient breast milk, problems of attachment and positioning. The authors conclude that health personnel should not only be motivated but also well trained on breastfeeding techniques and its problems.

¹Singh. D et al (2013). Nutritional Rehabilitation of Children < 6 months with Severe Acute Malnutrition. Indian J Pediatr DOI 10.1007/ s12098-013-1285-3 http://www.indianpediatrics.net/

²Operational guidelines on facility based management of children with severe acute malnutrition. 2011, Ministry of Health and Family Welfare, Government of India. Available from http://mohfw.nic.in/NRHM/Documents/CH/Operational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition.pdf.