Nutrition

NUTRITIONAL REHABILITATION CENTRE
1. Child under nutrition encompasses stunting (chronic malnutrition), wasting

(acute malnutrition) and deficiencies of micronutrients (essential vitamins and
minerals).
2. It significantly contributes to under five mortality as undernourished children
have increased susceptibility to infections and hence frequent episodes of
diarrhoea, acute respiratory infections, malaria and measles.
3. It also leads to growth retardation and impaired psychosocial and cognitive
development. This has impact on education attainment. The degree of
cognitive impairment is directly related to the severity of stunting and iron
deficiency anaemia.
4. Without treatment children who are affected by moderate/ sever acute
malnutrition during the critical stage of life between conception and age two, if
not provided with timely and quality care, will find it difficult to achieve their full
potential. Scientific evidence has shown that beyond the age to two to three
years, many effects of chronic under nutrition are irreversible. This means that
to break the intergenerational transmission of poverty and under nutrition,
children at risk must be reached during their first two years of life.
5. Screening for Malnutrition is done in the community as well as by Health Staff
by measuring weight and height in a given population.
6. Management of these severely malnourished children does not require
sophisticated facilities & equipments or highly qualified personnel. It does
require that each child be treated with proper care & affection, and that each
phase of treatment be carried out properly by approximately trained and
dedicated health personnel. When this is done, the risk of death can be
substantially reduced and the opportunity for full recovery greatly improved.
7. After treating the life-threatening problems in a hospital, the child with acute
malnutrition will be transferred to NRC for intensive feeding to recover lost
weight, development of emotional & physical stimulation, capacity building of
the primary caregivers of the child with acute malnutrition through sustained
counseling and continuous behavioral change activities. Thus NRC will be
intended to function as a bridge between hospital & home care. Hence, NRC
will be a short stay home for children with acute malnutrition along with the
primary care givers.
8. Objectives:
a. To provide institutional care for children with acute malnutrition.
b. To promote physical, mental & social growth of children with acute
malnutrition.
c. To build capacity of primary care givers in the home based
management of malnourished children.
d. Sick children with malnutrition are managed in hospitals where as
children without any disease are given feeding advise and regularly
measured and monitored in community by FHWs and AWWs.
9. For appropriate management of children with severe acute malnutrition the
government has established two Nutritional Rehabilitation Centres at IGMC,
Shimla and at Dr. RPGMC, Tanda.
10. Services to be provided at NRC
a. Treatment & Patient management.

b. Nutritional support to inmates.
c. Nutrition education to his/her family members.
d. Other counseling services viz. Family planning, Better hygiene
practices, Psycho-social care & development.
e. Capacity building of the primary caregivers on Preparation of low cost
nutritious diet from locally available food ingredients, Developing
Feeding habits & time management in mothers, imparting knowledge of
developing kitchen garden etc.
f. Follow up Services
Guidelines on “Operational Guidelines on Facility Based Management of

Children with Severe Acute Malnutrition-2011” on www.nrhm.gov.in
Reporting format : NRCs reporting format to be sent monthly

INFANT AND YOUNG CHILD FEEDING
Infant and Young Child Feeding is the single most preventive intervention for child
survival. It advocates the following:-
• Early initiation (within one hour of birth) and exclusive breast feeding till 6
months.
• Timely complementary feeding after 6 months with continued breast feeding
till the age of 2 yrs.
1. Breastfeeding
a) Breastfeeding should be promoted to mothers and other caregivers as the

gold standard feeding option for babies.
b) Pre-birth counselling individually or in groups organized by maternity facility

regarding advantages of breastfeeding and dangers of artificial feeding should
prepare expectant mothers for successful breastfeeding.
c) Breastfeeding must be initiated as early as possible after birth for all normal
newborns (including those born by caesarean section) avoiding delay beyond
an hour. In case of operative birth, the mother may need motivation and
support to initiate breastfeeding within the first hour.
d) Colostrum must not be discarded but should be fed to newborn as it contains

high concentration of protective immunoglobulins and cells. No pre-lacteal
fluid should be given to the newborn.
e) Baby should be fed "on cues"- sucking movements and sucking sounds, hand
to mouth movements, rapid eye movements, soft cooing or sighing sounds, lip
smacking, restlessness etc. Crying is a late cue and may interfere with
successful feeding. Periodic feeding is practiced in case of a very small infant
who is likely to become hypoglycemic unless fed regularly, on medical advice.
f) Exclusive breastfeeding should be practiced from birth till six months

requirements. This means that no other food or fluids should be given to the
infant below six months of age unless medically indicated. After completion of
six months of age, with introduction of optimal complementary feeding,
breastfeeding should be continued for a minimum for 2 years and beyond
depending on the choice of mother and the baby.
g) Mothers who work outside should be encouraged to continue exclusive

breastfeeding for 6 months by expressing milk for feeding the baby while they
are out at work, and initiating the infant on timely complementary foods.
h) Mothers who are unwell or on medication should be encouraged to continue

breastfeeding unless it is medically indicated to discontinue breastfeeding.
i) At every health visit, the harms of artificial feeding and bottle feeding should
be explained to the mother. Inadvertent advertising of infant milk substitute in
health facility should be avoided. Artificial feeding is to be practiced only when
medically indicated.
j) Anganwari workers would be trained in various skills of counselling and

especially in handling sensitive subjects like breastfeeding and
complementary feeding.
2. Complementary Feeding
a) Appropriately thick homogenous complementary foods made from locally

available foods should be introduced at six completed months to all babies
while continuing breastfeeding ad libitum.
b) Each meal must be made energy dense by adding sugar/jaggery and
ghee/butter/oil.
c) Foods can be enriched by making a fermented porridge, use of germinated or

sprouted flour and toasting of grains before grinding.
d) Parents must identify the staple homemade food comprising of cereal-pulse

mixture (as these are fresh, clean and cheap) and make them caloric and
nutrient rich with locally available products.
e) Bottle feeding shall be discouraged at all levels.
f) Iron-fortified foods, iodized salt, vitamin A enriched food etc. are to be

encouraged.
g) The food should be a "balanced food”. Easily available, cost-effective

seasonal uncooked fruits, green and other dark coloured vegetables, milk and
milk products, pulses/legumes, animal foods, oil/butter, sugar/jaggery may be
added gradually.
h) Avoid Junk food e.g. tinned foods/juices, cold-drinks, chocolates, crisps,

health drinks, bakery products etc
i) Avoid giving drinks with low nutrient value, such as tea, coffee and sugary
drinks.
j) Hygienic practices are essential during preparation, storage and feeding of

food. Hand washing with soap and water at times should be encouraged
before eating or preparing food and after using the toilet.
k) Young children should be encouraged to take feed by praising them and their
foods. Self-feeding should be encouraged despite spillage.
l) Along with feeding mother and care givers should provide psycho-social
stimulation to the child through age-appropriate play and communication
activities to ensure early childhood development.
The details of food including; texture, frequency and average amount are
enumerated in Table.
Table: Amount of Food to Offer at Different Ages
Average amount of each

Age Texture Frequency
meal
6-8 mo Start with thick porridge, 2-3 meals per day plus Start with 2-3
well mashed foods frequent Breastfeeding tablespoonfuls
9-11 Finely chopped or
3-4 meals plus breastfeed. ½ of a 250 ml cup/bowl
mo mashed foods,
and foods that baby can Depending on appetite offer
pick up 1-2 snacks
12-23 Family foods, chopped
3-4 meals plus breastfeed. 3/4 to one 250 ml cup/bowl
mo or mashed if necessary
Depending on appetite offer
1-2 snacks
If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day. The
amounts of food included in the table are recommended when the energy density of the meals is
about 0.8 to 1.0 Kcal/g. If the energy density of the meals is about 0.6 Kcal/g, recommend to
increase the energy density of the meal (adding special foods) or increase the amount of food per
meal. Find out what the energy content of complementary foods is in your setting and adapt the
table accordingly.
3. Feeding in Other Specific Situations
(a) Feeding during sickness is important for recovery and for prevention of under
nutrition. Even sick babies mostly continue to breastfeed and the infant can be
encouraged to eat small quantities of nutrient rich food but more frequently and by
offering foods that the child likes to eat. After the illness the nutrient intake of child
can be easily increased by increasing one or two meals in the daily diet for a period
of about a month; by offering nutritious snacks between meals; by giving extra
amount at each meal; and by continuing breastfeeding.
(b) Infant feeding in maternal illnesses
i. May need a temporary cessation of breastfeeding. Treatment of primary

condition should be done and breastfeeding started as soon as possible.
ii. Chronic infections like tuberculosis, leprosy, or medical conditions like
hypothyroidism need treatment of the primary condition and don’t warrant
discontinuation of breastfeeding.
iii. Breastfeeding is contraindicated when the mother is receiving certain
drugs like anti-neoplastic agents, immunosuppressants, anti-thyroid drugs
like thiouracil, amphetamines, gold salts, etc.

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NUTRITIONAL REHABILITATION CENTRE

1. Child under nutrition encompasses stunting (chronic malnutrition), wasting

a. Treatment & Patient management.

Guidelines on “Operational Guidelines on Facility Based Management of

Reporting format : NRCs reporting format to be sent monthly

a) Breastfeeding should be promoted to mothers and other caregivers as the

b) Pre-birth counselling individually or in groups organized by maternity facility

d) Colostrum must not be discarded but should be fed to newborn as it contains

f) Exclusive breastfeeding should be practiced from birth till six months

g) Mothers who work outside should be encouraged to continue exclusive

h) Mothers who are unwell or on medication should be encouraged to continue

j) Anganwari workers would be trained in various skills of counselling and

a) Appropriately thick homogenous complementary foods made from locally

c) Foods can be enriched by making a fermented porridge, use of germinated or

d) Parents must identify the staple homemade food comprising of cereal-pulse

f) Iron-fortified foods, iodized salt, vitamin A enriched food etc. are to be

g) The food should be a "balanced food”. Easily available, cost-effective

h) Avoid Junk food e.g. tinned foods/juices, cold-drinks, chocolates, crisps,

j) Hygienic practices are essential during preparation, storage and feeding of

Table: Amount of Food to Offer at Different Ages

Average amount of each

3. Feeding in Other Specific Situations

(b) Infant feeding in maternal illnesses

i. May need a temporary cessation of breastfeeding. Treatment of primary

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