United Nations Children’s Fund (UNICEF) estimated malnutrition (45%) to be the most common cause of under-five mortality, with India and Nigeria accounting for more than one-third of the deaths [1]. In India, prevalence of severe malnutrition (SAM) is 6.4% in children below 5 years with 100 focus districts having high prevalence of malnutrition being situated in 6 states: Bihar, Jharkhand, Madhya Pradesh, Rajasthan, Orissa and Uttar Pradesh [2,3]. For proper utilization of funds and manpower, there is phase-wise implementation of nutritional rehabilitation centers (NRC) in these areas by UNICEF. It is important to identify the treatment outcome from these existing nutritional rehabilitation centers.

The data of all the children with SAM admitted in the NRC were analyzed retrospectively in the Department of Pediatrics of MLN Medical College in Allahabad from January 2011 to December 2011. Children aged 6-59 months having SAM were admitted in the NRC if fulfilling the following criteria: (a) bilateral pitting edema and/or (b) weight-for-height < –3 SD and/or (c) mid-upper-arm circumference <115 mm.

One hundred and eighty two patients with SAM were admitted in the NRC during the study period. The mean (SD) age of patients was 17.8 (12.5) months; there were 96 males and 86 females. Edematous malnutrition was present in 31 (17%) patients. More than half (59.3%; n=108) were not breast fed and the rest were breastfeeding along with complementary foods at the time of admission. Edematous patients started losing edema at mean (SD) 3.2 (3.3) days. Non-edematous patients started gaining weight at mean (SD) 4.4 (3.9) days, and edematous patients started doing so at 11.4 (7) days. Twenty-six patients were discharged after fulfilling discharge criteria and 129 patients were discharged on request. Eighty-four patients out of 129 were cured during follow-ups. The outcome after 4 follow-ups was: 110 (60.4%) cured, 4 (2.2%) died, 4 (2.2%) not responded, 7 (3.3%) defaulted, 2 (1.1%) relapsed, 39 (21.4%) incomplete follow-up, and 16 (8%) medical transfers. Output indicators derived from these outcomes are given in Table I.

TABLE I Output Indicators of NRC

The study shows that output indicators were within the acceptable range (except for the cure rate) when children with SAM were managed in NRC. The primary failure was low as most of the patients also started gaining weight by day 4, edematous patients started losing edema by day 4 and were free of edema by day 10 [2].

The limitation of our study was that many patients were discharged on request for personal and social reasons. This led to high number incomplete follow-ups. The discharged patients were not seen by ASHA (Accredited social health activist) or ANM (auxilliary nurse midwife) which could have increased the follow-up.

Recovery rate in studies done by Teferi, et al. [5] and Hossain, et al. [6] was in the acceptable range (>75%) but in ours and in another recent study [7] it was below the acceptable range. This could be because of high number of defaulters along with less experience and teething problems of new NRCs. Most of the studies report average weight gain, average length of stay and death rate in the acceptable range [5-8]. The defaulter rate was low in our study as compared to study by Singh K, et al. [7]. This could be because we discharged many patients on request; many of them were cured during follow-ups, and were not included as defaulters. Some studies on home-based treatment reported higher relapse rate (6-11%) than ours because NRC staff conducted counseling sessions for care takers about nutrition and health of child [9].

We conclude that NRCs are effective in reducing mortality related to malnutrition. Patients can be discharged on request before the discharge criteria are met to decrease the defaulter rate. At the same time, NRCs should be attached with the community health schemes for proper management and follow-ups.

Contributors: MM and DKS: conceived and designed the study; MM and AS: collected the data, DKS and RR interpreted the data, MM and RR drafted the article, MM, AS and PKM revised the article; final approval was done by all.

Funding: NRC was funded by UNICEF; Competing interests: None stated.

1. Levels and Trends in Child Mortality. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. Report 2012. Available from: http://www.unicef.org/videoaudio/PDFs/UNICEF. Accessed February 27, 2014.

2. Operational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition, Ministry of Health and Family Welfare, Government of India, 2011. Available　from:　http://www.nihf.org/NCHRC-Publications/ Operational Guidelines. Accessed February 25, 2014.

3. HUNGaMA Fight for Hunger and Malnutrition, the HUNGaMA Survey Report, 2011. Available from: http://hungamaforchange.org/hungamBKDec11LR.pdf. Accessed February 27, 2014.

4. Ashworth A, Khanum S, Jackson A, Schofield C. Guidelines for Inpatient Treatment of Severely Malnourished Children, World Health Organization, 2003.

5. Teferi E, Lera M, Sita S, Bogale Z, Datiko DG, Yassin MA. Treatment outcome of children with severe acute malnutrition admitted to therapeutic feeding centers in Southern Region of Ethiopia. Ethiopion J Health Dev. 2010;24:234-38.

6. Hossain MI, Dodd NS, Ahmed T, Miah GM, Jamil KM, Nahar B, et al. Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh. J Health Popul Nutr. 2009;27:72-9.

7. Singh K, Badgaiyan N, Ranjan A, Dixit HO, Kaushik A, Aguavo VM, et al. Management of children with severe acute malnutrition in India; Experience of nutritional rehabilitation centre in Uttar Pradesh, India. Indian Pediatr. 2013;51:21-5.

8. Mamidi RS, Kulkarni B, Radhakrishna KV, Shatrugna V. Hospital based nutrition rehabilitation of severely undernourished children using energy dense local foods. Indian Pediatr. 2010;47:687-93.