Guidelines on Facility Based

Management of Malnourished
Children at
Bal Sewa Kendra
(CMTC)

Commissionerate of Health
Government of Gujarat, Gandhinagar
2012

1
 OPERATIONAL GUIDELINES
on Facility Based Management of
Malnourished Children at
" Bal Sewa Kendra"
( Child Malnutrition Treatment Centers)

Commissionerate of Health (CoH)

Government of Gujarat, Gandhinagar
2012

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 ABBREVIATIONS

AWW Anganwadi Worker

ASHA Accredited Social Health Acitivist
F- IMNCI Facility Based Integrated Management of Newborn and
Childhood Illness
IV Intravenous
IU International Unit.
HFA Height for Age
WFA Weight for Age
WFH Weight for Height
WFL Weight for Length
MUAC Mid Upper Arm Circumference.
VCNC Village Child Nutrition Center ( Bal Shaktim Kendra)
CMTC Child Malnutrition Treatment Center (Bal Sewa Kendra)
NRC Nutrition Rehabilitation Center ( Bal Sanjeevani Kendra)
SAM Severe Acute Malnutrition
SD Standard Deviation

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 CONTENTS
INTRODUCTION

SECTION 1: OPERATIONAL GUIDELINES: Planning and Implementation

Setting - Up of Bal Sewa Kendra ( CMTC) in a Health Facility
1. Understanding Malnutrition.
2. Situation of Malnutrition in Gujarat.
3. Rationale of Management of Children with Severe Underweight, Severe Acute
Malnutrition and Growth Faltering.
4. Approach for Management of Children with Severe Malnutrition.
5. Management of Severe Malnutrition under Mission Balam Sukham- Gujarat
6. Beneficiaries of Bal Sewa Kendra (CMTC).
7. Screening of Children at Bal Sewa Kendra (CMTC)
8. Principles of Hospital Based Management
9. Discharge from Bal Sewa Kendra (CMTC) to Bal Shaktim Kendra (VCNC).
10. Referred to Bal Sanjeevani Kendra (NRC) for higher level treatment.
11.Equipments and Supplies at Bal Sewa Kendra (CMTC).
12.Cost of Setting up Bal Sewa Kendra (CMTC)

SECTION 2: TECHNICAL GUIDELINES:

Medical Treatment and Management Protocols
1. Treatment of Hypoglycaemia.
2. Treatment of Hypothermia.
3. (a)Treatment of Dehydration in the children with SAM without shock.
(b) Management of Severely Acute Malnourished child with shock.
4. Correction of Electrolyte Imbalance.
5. Treatment of Infections
6. Micronutrient Supplementation.
7. Feeding Children with SAM
8. Catch up Growth in Rehabilitation Phase.
9. Structured Play Theraphy and Loving Care.
10.Prepare for Discharge and Follow up.

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 INTRODUCTION
1. UNDERSTANDING MALNUTRITION
Malnutrition refers to ‘undernutrition’ population are considered to be
resulting from inadequate severely stunted. Stunting reflects
consumption, poor absorption or failure to receive adequate nutrition
excessive loss of nutrients as also to over a long period of time and is also
‘overnutrition’, resulting from affected by recurrent and chronic
excessive intake of specific nutrients. illness.
An individual will experience
malnutrition if the appropriate Weight-for-height (wasting): This
amount or quality of nutrients measures body mass in relation to
comprising a healthy diet is not body length and describes current
consumed, or not absorbed nutritional status. Children whose Z-
adequately or not metabolized for an score is below minus two standard
extended period of time . The words deviations (<-2 SD) from the median of
malnutrition and undernutrition are the reference population are
used interchangeably in this considered thin (wasted) for their
document. height and are acutely malnourished.
Wasting represents the failure to
In children, malnutrition is
receive adequate nutrition in the
synonymous with growth failure -
period immediately preceding the
malnourished children are shorter and
survey and may be the result of
weigh less than they should be for
inadequate food intake or a recent
their age and height. Standard indices
episode of illness causing loss of
of physical growth that describe the
weight and the onset of malnutrition.
nutritional status of children are:
Children whose weight-for-height is
below minus three standard
Height-for-age (stunting) : This is an
deviations (<-3 SD) from the median of
indicator of linear growth retardation.
the reference population are
Children whose height-for-age Z-score
considered to be severely wasted.
is below minus two standard
deviations (<-2 SD) from the median of
Weight-for-age (underweight) : This is
the reference population are
a composite index of height-for-age
considered short for their age
and weight-for-height. It takes into
(stunted) and are chronically
account both acute and chronic
malnourished. Children below minus
malnutrition. Children whose weight-
three standard deviations (<-3 SD)
for-age is below minus two standard
from the median of the reference
deviations (<-2 SD) from the median

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 of the reference population are very low (<- 3 SD) in relation to height,
classified as underweight. Children when compared to WHO child growth
whose weight-for-age is below minus chart standards and or have Mid upper
three standard deviations (<-3 SD) Arm circumference <11.5cm and or with
from the median of the reference bi- lateral pitting odema symtoms.
population are considered to be
SAM is a severe form of wasting. Wasting
severely underweight (SUW). Severe
indicates current or acute malnutrition
Under weight (SUW) is the condition in
resulting from failure to gain weight or
which child weight is very low for the
actual weight loss. Faulty breast feeding
age and fall in to red classification of
practices , late and faulty complementary
WHO growth chart.
feeding , faulty child feeding practices,
Mid upper arm circumference repeated enteric and respiratory tract
(MUAC): This is an index for infections, sudden withdrawal of breast
measuring muscle wasting and loss of feeding replaced by over diluted top
subcutaneous fat. It is used for milk feeding are some of the factors
children in the age group 6 month to leading to Severe Acute Malnutrition (or
five years are concerned. Mid upper SAM) in children.
arm circumference <12.5 cm indicates
Clinical sign of wasting like baggy pant
wasting and that of <11.5 cm.
(as described in IMNCI) and bilateral
indicates severe wasting.
pitting oedema on legs are indicative of
Growth trend: Assessed by tracking severe acute malnutrition in need of
the weight gain of the child by age . medical attention. Loss of appetite in
Growth tracking reveals the direction malnourished child is an indication for
of growth curve. Upward growth early medical attention.
curve indicates whether the child is
Children with severe malnutrition like
growing or not. A downward trend
SUW, SAM, Serious growth faltering
indicates that child is loosing weight
need immediate nutrition rehabilitation
and is showing very dangerous growth
support and care.
trend indicating need for immediate
medical attention.
SAM: Severe Acute Malnutrition (SAM)
is a condition in which a child weight is

Malnourished Children in Need of Institutional Medical care

SUW / SAM / Child with dangerous growth trend

With any one or more of following

Infection, baggy pant sign, bilateral pitting oedema on both legs,

loss of appetite

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2. SITUATION OF MALNUTRITION growth faltering and taking corrective
measures before the child progresses
IN GUJARAT
to severe grades of malnutrition.
The National Family Health Survey Those children who have already
(2005-06) data on the nutrition status developed severe malnutrition require
of children in Gujarat shows that immediate nutritional care and
41.1% of under three and 45% under nutritional rehabilitation and amongst
five children are underweight. them those with one or more
Amongst Under three children 49.2% conditions like infection, loss of
are stunted and 19.7% are wasted. appetite, severe wasting, bilateral
(NFHS 3) pitting oedema on legs also need
In Gujarat Malnutrition prevalence immediate medical care along with
rate among children below three years nutrition rehabilitation.
is almost static between NFHS-2
(1998-99) (41.6 )and NFHS-3 (2005-
4. APPROACH FOR
06) (41.1%) .
Rate of under five children with (<3SD) MANAGEMENT OF CHILDREN
weight for height which is a cut off for WITH SEVERE MALNUTRITION
SAM is 5.8%.
There are two approach for
3. RATIONALE OF MANAGEMENT management of children
OF CHILDREN WITH SEVERE
1. Inpatient or Facility Based
UNDERWEIGHT, SEVERE ACUTE management: It has been seen that
MALNUTRITION AND GROWTH only about 10-15% children with
FALTERING Severe Acute Malnutrition present
with complications requiring
Children with severe malnutrition are inpatient care.
at increased risk of mortality due to
common childhood illnesses since they 2. Community based management:
have reduced immunity and in some Approximately 85-90% of severely
cases deranged metabolic malnourished children who do not
system.Severely malnourished have complications can be taken
children contribute significantly to care of on an outpatient basis in
deaths in children under the age of the community setting. In addition,
five years. those children discharged from the
It is important to recognize that institutional care are also to be
malnutrition is a preventable and continued for care at community
treatable cause of morbidity and setting after stabilization and
mortality and therefore there is an onset of recovery phase.
urgent need to have in place
mechanisms for early detection of
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 Community Based Care program setting itself thus reducing the
would complement the services demand on resources and health
delivered through indoor facilities.
institutional care and create scope
for the majority of children to be
provided care in the community

5. MANAGEMENT OF SEVERE MALNUTRITION UNDER MISSION BALAM

SUKHAM- GUJARAT

Gujarat Model

In Gujarat state under “Mission Balam malnourished children without

Sukham” (Gujarat State Nutrition complications at Anganwadi
Mission) three tier system of Nutrition Centers ”(AWCs).
Care, support, rehabilitation and
treatment of severely malnourished 2. Bal Sewa Kendra: The second level
children is planned. is Institutional care for inpatient
management and treatment of
1. Bal Shaktim Kendra: The first level severely malnourished children
is a community based care for the with complications at CHCs.
management and support of

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Bal Sanjeevani Kendra: The tertiary severe complications at district
level institutional care (NRC) is for hospitals and Medical college
inpatient management and treatment hospitals.
of severely malnourished children with

6. BAL SEWA KENDRA BENEFICIARIES

Children with SAM, SUW and Serious cases for minimum 21 days. (This
growth faltering with one or more strategy is a state adaptation and
of the conditions like infection/ loss differs from GOI guidelines for
of appetite/ bilateral pitting oedema institutional management of
on legs are beneficiaries of Bal Sewa malnutrition which is focussed on
Kendra and shall be treated as indoor SAM children only)

B-1) OPD case with

Severe malnutrition
B-2) Indoor cases
without discharged after
infection/oedema/
21 days
loss of appetite shall management shall
A-2) Case referred from be referred to "Bal be referred to to
"Bal Shaktim Kendra" & Shaktim Kendra" "Bal Shaktim
"Mamta Diwas " Kendra"

C)
A-1) OPD case with Bal Cases referred to
Bal Sewa Kendra and in
Severe malnutrition
and Sewa need of tertiary care
shall be referred to
infection/oedema/
Kendra Bal Sanjeevani Kendra
loss of appetite

Bal Sewa Kendra shall receive referrals A- 1) All under five children attending
for management of nutrition and OPD at PHC and CHC shall be assessed
medical condition (A) and also refer for Wt/Age, Wt/Ht, MUAC. A child
back for first level community based with SAM/ SUW / Serious growth
care at AWC. faltering with one or more of the
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 conditions like infection/ loss of condition like infection/ loss of
appetite/ bilateral pitting oedema on appetite/ oedema shall be referred
legs are beneficiaries of Bal Sewa back to “Bal Shaktim Kendra” of
Kendra and shall be treated as indoor AWC of their residential area and
cases. shall be managed for nutrition care
and support for 30 working days as
A- 2) All under five children attending
per guidelines of “Bal Shaktim
AWC , MAMTA divas or assessed at
Kendra”
community level for Wt/Age during
regular weighing session shall be B-2) Child managed at “Bal Sewa
assessed for MUAC by ANM as per the Kendra” for minimum 21 days and
guidelines of “Bal Shaktim Kendra” . A fulfils the discharge criteria shall be
child with SAM/ SUW / Serious referred back to “Bal Shaktim Kendra”
growth faltering with one or more of from where the child was referred / of
the conditions like infection/ loss of the residence of (village) of the child
appetite/ bilateral pitting oedema on for nutritional care and support
legs shall be referred to “Bal Sewa
Kendra”, and shall be treated as C) . Cases detected or referred at “Bal
indoor cases. Sewa Kendra” in need of tertiary level
care and management shall be
B-1) PHC/CHC/DH OPD cases detected referred to “Bal Sanjeevani Kendra”
as SAM/SUW/ Serious growth (DH/Medical college hospital)
faltering without any of the

7. SCREENING OF CHILDREN AT BAL SEWA KENDRA

a) All children attending OPD of b) Criteria for admission of child at

CHC/PHC and referred to Bal Sewa Bal Sewa Kendra shall be
Kendra shall be screened for
1. Child with SAM, detected as (<-3
 Weight sd) weight to height and or
 Height MUAC <11.5cm.
 MUAC 2. Severely Under weight children
 Wt/Age
(Red classification of WHO
 Wt/Height
growth chart)
 Clinical examination for
infections (F IMNCI) 3. Under weight child showing
 Oedema serious growth faltering
 Anemia (declining trend of growth line
 Vit.A deficiency between two consecutive
measures)

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  Child from 1-3 category along c. Fails in Appetite test
with one or more of the
following conditions i.e.
a. Infection (detected by a
paediatrician or by MO as
per FIMNCI protocol
b. Pitting Oedema on both
legs or body,

8. PRINCIPLES OF HOSPITAL - BASED MANAGEMENT

The principles of management of SAM are based on 3 phases : Stabilization Phase,
Transition Phase and Rehabilitation Phase.:

Stabilisation Phase: Children with Transition Phase from Stabilization

SAM without an adequate appetite Phase when there is -
and/or a major medical
 At least the beginning of loss
complication are stabilized in an in-
of oedema
patient facility. This phase usually
&
lasts for 1 - 2 days. The feeding
 Return of appetite
formula used during this phase is
&
Starter diet (F-75/ optional dietary
formula 1 – Annexure no 4 ) which  No nasogastric tube,
promotes recovery of normal infusions, no severe medical
metabolic function and nutrition- problems
electrolytic balance. All children &
must be carefully monitored for  Is alert and reactive
signs of overfeeding or over The ONLY difference in management
hydration in this phase. of the child in transition phase is the
Transition Phase: This phase is the change in type of diet. There is gradual
subsequent part of the stabilization transition from Starter diet to Catch-
phase and usually lasts for 2-3 days. up diet (F-100/ optional dietary
The transition phase is intended to formula 2- Annexure no 4 ).The
ensure that the child is clinically quantity of Catch-up diet given is
stable and can tolerate an equal to the quantity of Starter diet
increased energy and protein given in stabilization Phase.
intake. The child moves to the Rehabilitation Phase: Once children
with SAM have recovered their
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appetite and received treatment for o child has reasonable appetite;
medical complications they enter finishes > 90% of the feed that is
Rehabilitation Phase. The aim is to given, without a significant
promote rapid weight gain, stimulate pause
emotional and physical development o Major reduction or loss of
and prepare the child for normal oedema
feeding at home. The child progresses o No other medical problem
from Transition Phase to
Rehabilitation Phase when:

9. DISCHARGE FROM " BAL SEWA KENDRA" TO "BAL SHAKTIM KENDRA'

Criteria of discharge of the SAM child  No oedema
from Bal Sewa Kendra and transfer  Caretakers sensitized to home
over to Bal ShaktiM Kendra: care and education has been
completed
 Child has completed antibiotic  Immunization is up- to- date
treatment
 Has good appetite ( eating at Child is to be referred from Bal Sewa
least 120-130 cal/kg/day) Kendra to the Bal shaktim Kendra of
 Has good weight gain ( of at the village from where child was
least 5g/kg/day for three referred
consecutive days) on exclusive
oral feeding

10. REFERRED TO "BAL SANJEEVANI KENDRA" (NRC) FOR HIGHER LEVEL

TREATMENT
Child to be referred to NRC in case of failure to respond to the treatment and
management at “Bal Sewa Kendra”
Failure to Respond Citeria Approximate time after admission
 Failure to regain appetite – Day 4
 Failure to start to lose oedema – Day 4
 Oedema still present – Day 10
 Infection not responding to treatment
 HIV/ TB infection in child
 General condition of the child worsens
 Failure to gain at least 5 g/kg/day for 3 successive days after feeding freely on
Catch-up diet.
These children should be referred to NRC with continuation of appropriate care
and treatment and an attendant who can manage emergency.

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11. BASIC EQUIPMENTS AND SUPPLIES AT BAL SEWA KENDRA
List of Equipments and Supplies at Bal Sewa Kendra (CMTC).

S.no Item Quantity Unit Cost Total Cost Source

(Approx)

1 Length Board 1 1000

2 Electronic Weighing 1 6000

machine

3 MUAC Tapes 2

4 Measuring Cups and 2 Set 300

Spoons

5 LPG Connection and Stove 1 7000 7000

(4 burners)

6 Storage Tins for Kitchen 10 100 1000

7 Feeding Utensils- Katori, 20 150 3000

Spoon, Plates, glasses

8 Cooking Utensils 5000

9 Geyser for Bathrooms 1 5000 5000

10 Refrigerator 1 10000 10000

11 Water Purifier 1 10000 10000

12 Mixer 1 6000 6000

13 Room Heater 1 2500 2500

14 Room Thermometer 1 100 100

15 Digital Thermometers for 2 200 400

children

16 Baby blankets 10 200 2000

17 Blankets for mothers 10 400 4000

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18 Mosquito nets 10 100 1000

19 Bed sheets 20 100 2000

20 Mattresses 10 500 5000

21 Cots 10 2000 20000

22 Chairs 4 1500 6000

23 Table 2 3000 6000

24 Soft Boards 2 1500 3000

25 White Boards 2 2000 4000

26 TV with DVD Player 1 25000 25000

27 Panels of Protocol and 2000 2000

treatment

28 Dari, Chatai, aasan etc 2 each 100 2000

29 Dustbin, doormats, shoe 2 each 100 2000

racks

30 Trunks/ Bedside Cabinets 10 1000 10000

31 MIS Register, SAM charts,

Admission, Discharge and
Follow up Cards 5000
32 Transfer slips form CMTC to
VCNC, CMTC to NRC

33 Toys for Children 1000 1000

34 Wall painting to make NRC 7,000 7,000

child friendly.

Total 1,64,300

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12. COST OF SETTING UP BAL SEWA KENDRA (CMTC)
Human Resources / Running Cost per month in 1 facility

S.no. Staff Posting for Unit Cost Total Cost Source

10 beds
1 Medical Officer 1 Attached from District Hospital
2 Nutritionist 1 8500 8500
3 Staff Nurse/ANM/FHW 1 Attached from District Hospital
4 Cook cum Care taker 2 3500 7000
5 Attendant / Cleaner 1 3000 3000
6 Contingency 1 2000 2000
Total Total Cost 17,000 20,500

Cost of Treatment / Child (10 children/ month in a 10 bed centre)

10 children / batch for 21 days

S# Item and Quantity Unit Cost Calculation Total Cost (10

children *
Rs…..* 21
days)
1 Food for Children* Rs 100 / day 10 child * Rs 100 21,000
*( Rs 60 for food & Rs * 21 days
40 for medicines /day)
2 Wage loss Rs 100/ 10 child * Rs 100 21,000
compensation for mother/day * 21 days
mothers
3 Reimbursement of Rs 200/- per child Rs 200 * 10 2,000
transportation cost to mothers
mothers for bringing
the child to the facility
( to and fro)
4 Incentive to ASHA / Rs 100 /- per Rs 100*10 ASHA 1,000
AWW for child / AWW
accompanying the
child to NRC

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5 Reimbursement of Rs 200/follow up Rs 200*4 follow 8,000
transportation cost to visit/child ups *10 children
mothers for bringing
the child to facility – to
& fro in follow up
visits
6 Incentive to ASHA/ Rs 100/follow up Rs 100*4 follow 4,000
AWW visit / child ups *10 children
For accompanying
child to CMTC in
Follow up visits
7 Wage loss Rs 100/follow up Rs 100*4 follow 4,000
compensation for visit/child ups*10 children
mothers in follow up
visits
Tot 61, 000

Cost of treating one child

S# Heads For 10 Bed facility (Rs)

1 Fixed cost per month per CMTC 20,500
2 Cost of treating per child/ month inclusive of 61,000
follow ups
Tot 81,500
Cost of treating Rs 8150 per child.

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2
SECTION

TECHNICAL
GUIDELINE

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MEDICAL TREATMENT AND MANAGEMENT PROTOCOLS:

1. TREATMENT OF HYPOGLYCAEMIA:

Estimate Blood Glucose levels

(Using glucometer or drawing blood sample for lab. tests)

If blood glucose is low (< 54 mg/dl) or hypoglycaemia is suspected, immediately

give the child a 50 ml bolus of 10% glucose or 10% sucrose (1 rounded teaspoon of
sugar in 3½ tablespoons of water). (Glucose is preferable because the body can use
it more easily.)

If the child can drink, give the 50 ml bolus orally.

If the child is alert but not drinking, give the 50 ml by NG tube.

If the child is lethargic, unconscious, or convulsing, give 5 ml/kg body weight of

sterile 10% glucose by IV, followed by 50 ml of 10% glucose or sucrose by NG tube.*
If the IV dose cannot be given immediately, give the NG dose first. (* If the child will
be given IV fluids for shock, there is no need to follow the 10% IV glucose with an
NG bolus, as the child will continue to receive glucose in the IV fluids.)

Start feeding with ‘Starter diet’ half an hour after giving glucose and give it every
half-hour during the first 2 hours. For a hypoglycaemic child, the amount to give
every half-hour is ¼ of the 2-hourly amount (refer to Annexure 5 & 6 for calculation
of the amount of feed).

Keep child warm (described in step-2) as hypoglycemia and hypothermia coexist.

Administer antibiotics as hypoglycaemia may be a feature of underlying infection

(as described in step-5).

If blood glucose is normal (> 54mg/dl), start giving ‘Starter Diet’, 2 hourly. (Refer to
Annexure 5 & 6 for calculation of the amount of feed).

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 2. TREATMENT OF HYPOTHERMIA:

Take temperature
(Preferably using a low-reading thermometer; range 29°C – 42°C)

If axillary temperature is below 35°C

Or
Rectal temperature is below 35.5°C

 Start feeding immediately (or start rehydration if needed).

 Re-warm. Put the child on the mother’s bare chest (skin to skin contact: kangaroo
technique) and cover them, OR clothe the child including the head, cover with a
warmed blanket and place a heater or lamp nearby.
 Remove wet clothing/bedding
 Feed 2-hourly (12 feeds in 24 hours).
 Treat hypoglycaemia,
 Give 1st dose of antibiotics
Monitor during re-warming
 Take temperature every two hours: stop re-warming when it rises above 36o C
 Take temperature every 30 minutes if heater is used
If rectal temperature < 32°C

Treat for Severe Hypothermia

 Give warm humidified oxygen.
 Give 5 ml/kg of 10% dextrose IV immediately or 50 ml of 10% dextrose by
nasogastric route (if intravenous access is difficult).
 Provide heat using radiation (overhead warmer), or conduction (skin contact) or
convection (heat convector). Avoid rapid rewarming , monitor temperature every
30 minutes
 Give warm feeds immediately, if clinical condition allows the child to take orally,
else administer the feeds through a nasogastric tube. Start maintenance IV fluids
(prewarmed), if there is feed intolerance/contraindication for nasogastric feeding.
 Rehydrate using warm fluids immediately, when there is a history of diarrhea or
there is evidence of dehydration.
 Start intravenous antibiotics

Do not use hot water bottles due to danger of burning fragile skin.

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3. TREATMENT OF DEHYDRATION IN THE CHILDREN WITH SAM
WITHOUT SHOCK.

Give Re So Mal oral rehydration solution as follows, in amounts based on the

child’s weight:
How often to give ORS (ReSoMal) Amount to give
Every 30 minutes for first 2 hours 5 ml/kg weight

Alternate hours for up to 10 hours 5-10 ml/kg*

*The amount offered in this range should be based on child’s willingness to

drink and amount of ingoing losses in stool. Starter diet is given in alternate
hours (eg. 2,4,6) with reduced osmolarity ORS (eg. 3,5,7) until the child is
rehydrated.
Signs to check every half hour for the first two hours, then hourly:
 Respiratory rate
 Pulse rate
 Urine frequency
 Stool or vomit frequency
 Signs of hydration
Signs of over hydration
 Increased respiratory rate and pulse. (Both must increase to consider it a
problem –increase of Pulse by 15 & RR by 5)
 Jugular veins engorged
 Puffiness of eye
Stop ORS if any of the following signs appear.
Signs of improved hydration status (any 3 of the following):
 Child is no longer thirsty
 Child is less lethargic
 Slowing of respiratory and pulse rates from previous high rate
 Skin pinch is less slow
 Tears
If diarrhoea continues after rehydration, give ORS after each loose stool to
replace ongoing losses:
 For children less than 2 years, give approx 50 ml after each loose stool
 For children 2 years and older, give 100 ml after each loose stool
Breast feeding is continued with increased frequency if the child is breastfed.

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MANAGEMENT OF SEVERELY ACUTE MALNOURISHED CHILD, WITH
SHOCK.

A severely malnourished child is considered in shock if s/he is:

 Lethargic or unconscious and
 Has cold hands
Plus either:
 Slow capillary refill (more than 3 seconds)
Or
 Weak or fast pulse
Give this treatment only if the child has signs of shock and lethargic or has lost conciousness
 Weigh the child . estimate the weight if the child can not be weighed or weight not
known
 Give Oxygen
 Make sure that the child is warm
Insert an IV line and collect blood for Emergency Laboratory Investigation

Give IV 10% Glucose (5ml./kg)

Give IV 15ml./kg in 1 hour of either

Ringer’s Lactate in 5% Dextrose
or
Half normal saline with 5% Glucose/ Ringer” Lactase

Measure pulse and Breathing rate at start and every 5-10 minutes

Signs of If Child fails to If the child deteriorates

Improvement improve after during IV Rehydration
Pulse rate & first 15ml/kg IV
Respiratory Rate (RR increase by 5/Min.or
falls PR increases by 15/Min.)

Stop infusion and

reassess
 Repeat same IV
fluid 15ml/kg for 1
hour Assume that the child has a septic shock
Then switch over to
 ORS orally/ by
nasogastric tube
10ml/kg/hr for 10  Give maintenance IV fluid
hours 4ml/kg/h
 Initiate re feeding  Give Antibiotics
with starter formula  Give Dopamine
 Start re feeding as soon as
possible

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4.CORRECTION OF ELECTROLYTE IMBALANCE

Normally the body uses energy to maintain appropriate balance of potassium

inside the cells and sodium outside the cells. In severely malnourished children
the level of sodium in the cells rises and potassium leaks out due to reductive
adaptation.

Therefore all severely malnourished children should be given potassium to

make up for what is lost. Magnesium is essential for potassium to enter the
cells and be retained. Malnourished children already have excess sodium in
their cells, so sodium intake should be restricted.

In order to correct electrolyte imbalance:

 Give supplemental potassium at 3–4 meq/kg/day for at least 2 weeks.

Potassium can be given as syrup potassium chloride; the most common
preparation available has 20 meq/15ml. It should be diluted with water.

 On day 1, give 50% magnesium sulphate IM once (0.3 mL/kg) up to a

maximum of 2 ml. Thereafter, give extra magnesium (0.4 – 0.6
mmol/kg/daily) orally. If oral commercial preparation is not available you
can give injection magnesium sulphate (50%); 0.2–0.3 ml/kg orally as
magnesium supplements mixed with feeds. Give magnesium supplements
for 2 weeks.

 Give food without added salt to avoid sodium overload.

 Do not treat oedema with diuretics

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5. TREATMENT OF INFECTIONS

If the child appears to have no complications give:

Oral amoxicillin 15mg/kg 8-hourly for 5 days

If child has complications (eg; septic shock, hypoglycaemia, hypothermia, skin

infections or dermatosis, respiratory or urinary tract infections, or
lethargic/sickly appearance), select antibiotic as shown in the table below:

23
6. MICRONUTRIENT SUPPLEMENTATION

Vitamin A: Give Vitamin A in a single dose to all SAM children unless there is
evidence that child has received vitamin A dose in last 1 month.

Recommended oral dose of Vitamin A according to child’s age

 Give same dose on Day 1, 2 and 14 if there is clinical evidence of vitamin A

deficiency.
 Children more than twelve months but having weight less than 8 kg should
be given 100,000 IU orally irrespective of age.
 Oral treatment with vitamin A is preferred, except for initial treatment of.
For oral administration, an oil-based formulation is preferred.
 IM treatment should be used in children with severe anorexia, oedematous
malnutrition, or septic shock. Only water-based formulations and half of
oral dose should be used.

Other micronutrients should be given daily for at least 2 weeks:

 Multivitamin supplement (should contain vitamin A, C, D, E and B12 and
not just vitamin B-complex): Twice Recommended Daily Allowance
 Folic acid: 5 mg on day 1, then 1 mg/day
 Elemental Zinc: 2 mg/kg/day
 Copper: 0.3 mg/kg/day (if separate preparation not available use
commercial preparation containing copper)
 Iron: Start daily iron supplementation after two days of the child being on
Catch up formula (F 100). Give elemental iron in the dose of 3 mg/kg/day in
two divided doses, preferably between meals. (Do not give iron in
stabilization phase.)

24
7. FEEDING CHILDREN WITH SAM

Cautious feeding in stabilization phase

 Feeding should begin as soon as possible after admission with ‘Starter diet’
until the child is stabilized. This is a phase when the child recovers normal
metabolic function and nutrition-electrolytic balance and but there is NO
weight gain.
 Severely malnourished children cannot tolerate usual amounts of protein
and sodium at this stage, or high amounts of fat. Starter diet is low in
protein and sodium and high in carbohydrate, which is more easily handled
by the child and provides much-needed glucose contains 75 kcal and 0.9 g
protein per 100 ml. (Recipe for preparing ‘Starter diet’ is given in Annexure
4)
 Give starter formula , calculating the required daily amount for each child
using Starter diet Reference Card given in annexure 5 & 6.
 Give 8-12 feeds over 24 hours
 If the child has gross oedema, reduce the volume to 100 ml/kg/day (see
feed chart for amounts)
 If the child has poor appetite, coax and encourage the child to finish the
feed. If eating 80% or less of the amount offered, use a nasogastric tube. If
in doubt, see feed chart for intakes below which tube feeding is needed.
 Keep a 24-hour intake chart. Measure feeds carefully. Record leftovers.
 If the child is breastfed, encourage continued breastfeeding but also give
starter formula.
 Transfer to starter formula as soon as appetite has returned (usually within
one week) and oedema has been lost or is reduced
 Weigh daily and plot weight.

25
8. CATCH UP GROWTH IN REHABILITATION PHASE

Feeding for Catch up growth

Catch-up diet is started to rebuild wasted tissues once the child is stabilized.
(Recipe in annexure 4) Catch-up diet contains more calories and protein: 100
kcal and 2.9 g protein per 100 ml. During this phase there is rapid weight gain.
The required daily amount for each child can be calculated using Catch-up diet
Reference Card.

 Change to catch-up diet: For 2 days, replace starter formula with the same
amount of catch-up diet ;on the next day increase each feed by 10ml until
some feed remains uneaten
-

 Give 8 feeds over 24 hours. These can be 5 feeds of catch-up diet and 3
specially modified family meals, high in energy and protein.

 Encourage the child to eat as much as possible, so the child can gain weight
rapidly. If the child is finishing everything, offer more and increase
subsequent feeds. Make sure that the child is actively fed.

 Weigh daily and plot weight on Record card.

Note: F-75 and F-100 are pharmaceutically prepared products (as per WHO
guidelines) that deliver calories, proteins, electrolytes and minerals as required
by children with SAM, promoting weight gain as well as functional and
immunological recovery. Till the time commercially produced F 75, F 100 is
freely available, similar diet can be prepared using locally available products as
per the recipes given in annexure 4.

26
9. STRUCTURED PLAY THERAPY AND LOVING CARE

 Emotional and physical stimulation can substantially reduce the risk of

permanent mental retardation and emotional impairment.

 After the first few days of treatment, the child should spend prolonged
periods with other children on large play mats and with the mother.

 Each play session should include language and motor activities, and
activities with toys. Teach the child local songs and games using the
fingers and toes. Encourage the child to laugh, vocalise and describe
what he or she is doing. Encourage the child to perform the next
appropriate motor activity, for example, help the child to sit up; roll
toys out of reach to encourage the child to crawl after them; hold the
child’s hands and help him or her to walk.

 Physical activity promotes the development of essential motor skills

and may also enhance growth. For immobile children, passive limb
movements should be done at regular intervals. For mobile children,
play should include such activities as rolling or tumbling on a mattress,
kicking and tossing a ball, and climbing stairs etc. Duration and
intensity of physical activities should increase as the child’s condition
improves.

 Mothers and care givers should be involved in all aspects of

management of her child. Mothers can be taught to: prepare food;
feed children; bathe and change; play with children, supervise play
sessions and make toys.

 Mothers must be educated about the importance of play and

expression of her love as part of the emotional, physical and mental
stimulation that the children need.

27
10. PREPARE FOR DISCHARGE AND FOLLOW UP

The average stay in a hospital setting varies between 10 to 15 days (but can be
longer), depending on each child’s medical recovery. However the child
requires follow up for another 4-6 months for full recovery, depending upon
the child’s progress at home. Therefore parent/caregivers must be prepared for
discharge and follow up.
 Before being discharged from the facility, child must become accustomed to
eating family meals. While the child is in the ward, gradually reduce and
eventually stop the feeds of Catch-up diet, while adding or increasing the
mixed diet of home foods, until the child is eating as s/he will eat at home.
 Ensure that parent/caregiver understands the causes of malnutrition and
how to prevent its recurrence by following correct breastfeeding and
feeding practices (frequent feeding with energy and nutrient dense foods).
 Treatment for helminthic infections should be given to all children before
discharge. Give a single dose of any one of the following antihelminthics
orally:
o 200 mg. albendazole for children aged 12–23 months, 400 mg
Albendazole for children aged 24 months or more.
o 100 mg Mebendazole twice daily for 3 days for children aged 24
months or more.
 Before discharge, inform the ANM posted at the nearest PHC or sub-centre
in order to ensure follow up.

 Discharge the child with referral back slip and record card

 Refer back the child to “Bal shaktim Kendra” from where the child was
referred or the from the area child belongs to.
 Inform the parents for the
o Importance of follow-up visits.
o Need for Regular check-ups at 2 weeks in first month and then
monthly thereafter until weight for height reaches -1 SD or above.
o If there is any health or weight gain problem detected or suspected,
more frequent visits at “Bal shaktim Kendra” and even a “visit to Bal
sewa Kendra”. visit/s can be made earlier or more frequently until the
problem is resolved.

28
ANNEXURE 1.

Weight – for – Length Reference Card (Below 87 cm)

Boy’s weight (kg) Length Girls Weight (kg)
-4 SD -3 SD -2 SD -1 SD Median (cm) Median -1 SD -2 SD -3 SD -4 SD
1.7 1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9 1.7
1.8 2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0 1.9
2.0 2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2 2.0
2.1 2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3 2.1
2.2 2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4 2.2
2.4 2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6 2.4
2.5 2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8 2.5
2.7 2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9 2.7
2.9 3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1 2.8
3.1 3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3 3.0
3.3 3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5 3.2
3.5 3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7 3.4
3.7 4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9 3.6
3.9 4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1 3.8
4.1 4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3 3.9
4.3 4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5 4.1
4.5 4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7 4.3
4.7 5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9 4.5
4.9 5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1 4.7
5.1 5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3 4.8
5.3 5.7 6.2 6.7 7.3 65 7.1 6.4 5.9 5.5 5.0
5.5 5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6 5.1
5.6 6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8 5.3
5.8 6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0 5.5
6.0 6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1 5.6
6.1 6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3 5.8
6.3 6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5 5.9
6.4 7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6 6.0
6.6 7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8 6.2
6.7 7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9 6.3
6.9 7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1 6.5
7.0 7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2 6.6
7.2 7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4 6.7
7.3 7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5 6.9
7.4 8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7 7.0
7.6 8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8 7.1
7.7 8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0 7.3
7.9 8.6 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1 7.5
8.0 8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3 7.6
8.2 8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5 7.8
8.4 9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7 8.0
8.6 9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9 8.1

29
ANNEXURE 2.

Weight-for-Height Reference Card (87 cm and above)

Boys’weight (kg) Height Girls’ weight (kg)
-4 SD -3 SD -2 SD -1 SD Median (cm) Median -1 SD -2 SD -3 SD -4 SD
8.9 9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2 8.4
9.1 9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4 8.6
9.3 10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6 8.8
9.4 10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8 9.0
9.6 10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0 9.1
9.8 10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2 9.3
9.9 10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4 9.5
10.1 11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6 9.7
10.3 11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8 9.8
10.4 11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9 10.0
10.6 11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1 10.2
10.8 11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3 10.4
11.0 11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5 10.5
11.2 12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7 10.7
11.3 12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0 10.9
11.5 12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2 11.1
11.7 12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4 11.3
11.9 13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6 11.5
12.1 13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9 11.8
12.3 13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1 12.0
12.5 13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4 12.2
12.7 13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7 12.4
12.9 14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9 12.7
13.2 14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2 12.9
13.4 14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5 13.2
13.6 14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8 13.5
13.8 15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1 13.7
14.1 15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4 14.0
14.3 15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7 14.3
14.6 16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0 14.5
14.8 16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3 14.8
15.0 16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6 15.1
15.3 16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9 15.4
15.5 17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3 15.6

30
 ANNEXURE 3.

Appetite Test
The complications in malnutrition lead to loss of appetite. Appetite test helps in identifying SAM
Children with medical complications who will need hospitalization. Children who have good appetite
can nutritional rehabilitation in community settings.

How to do Appetite test?

 Do the test in a separate quite area.

 Explain to the mother/caregiver how the test will be done.
 The mother/caregiver should wash her hands.
 The mother sits comfortably with the child on her lap and offers therapeutic food.
 The child should not have taken any food for the last 2 hrs.
 The test usually takes a short time but may take up to one hour.
 The child must not be forced to take the food offered.
 When the child has finished, the amount taken is judged or measured.
What foods to be offered for appetite test?

Appetite has been standardized using RUFT (Ready to use Therapeutic Feeds). There is lake of
scientific evidence regarding the feasibility of appetite test using locally prepared therapeutic feeds.
Based on the nutritional needs, an experience from Pilot studies the suggested method of testing of
appetite is as follow.

 For Children 7 – 24 months : Offer 30-35 ml/kg of Catch-up diet (F-100), If the child takes
more than 25 ml/kg then the child should be considered to have good appetite.
 For Children > 12 months : Following food items may be offered.
How to Prepare
a) Roasted ground nuts 1000 gm
b) Milk Powder 1200 gm
c) Sugar 1120 gm
d) Coconut Oil 600 gm
 Take roasted ground nuts and grind them mixer.
 Grind Sugar separately or with roasted ground nuts.
 Mix ground nuts, sugar milk powder and coconut Oil
 Store them in air tight container
 Prepare only for one week to ensure the quality of feed
 Store in refrigerator
Amount of local therapeutic feed that a child with SAM should taken to PASS the appetite
test.
Body Weight (kg) Weight in grams
Less than 4 kg 15g or more
4-7 kg 25g or more
7-10 33g or more

31
ANNEXURE 4.

Composition for starter and catch up diet ( as per WHO recommended

F-75 and F- 100)
Contents per 100 ml Starter diet Catch- up diet
Protein (g) 0.9 2.9
Lactose (g) 1.3 4.2
Potassium (mmol) 4.0 6.3
Sodium (mmol) 0.6 1.9
Magnesium (mmol) 0.43 0.73
Zinc (mg) 2.0 2.3
Copper (mg) 0.25 0.25
% energy from protein 5 12
% energy from fat 36 53
Osmolarity (mOsmol/1) 413 419

Recipe for starter diet

Contents ( per 1000 ml) Starter diet Starter diet ( Cereal based)
Fresh Cow’s or equivalent milk ( e.g. toned 300 300
dairy milk) (ml)
Sugar (g) 100 70
Cereal flour:
Powdered puffed rice (g) - 35
Vegetable oil (ml) 20 20
Water: make up to (ml)** 1000 1000
Energy (kcal/100ml) 75 75
Protein (g/100 ml) 0.9 1.1
Lactose (g/100 ml) 1.2 1.2
*Adapted from IAP Guidelines 2006.** Important note about adding water : Add just the amount of water needed to make 1000ml of Starter diet.
Do not simply add 1000 ml of water, as this will make the diet too dilute. A mark for 1000 ml should be made on the mixing container for the diet, so
that water can be added to the other ingredients up to this mark.
Recipe for catch up diet

Contents ( per 1000 ml) Catch –up diet

Cow’s milk/ toned dairy milk (ml) 900
Sugar (g) 75
Vegetable oil (g) 20
Water to make (ml) 1000
Energy (kcal/100ml) 100
Protein (g/100 ml) 2.9
Lactose (g/100 ml) 4.2

32
ANNEXURE 5.
Starter (F-75)diet reference Card
Weight of Volume of F-75 per feed (ml) Daily total 80% of daily
child (kg) Every 2 hours Every 3 hours Every 4 hours (130 ml/kg) total
(12 feeds) (8 feeds) (6 feeds) (minimum)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
4.8 55 80 105 624 500
5.0 55 80 110 650 520
5.2 55 85 115 676 540
5.4 60 90 120 702 560
5.6 60 90 125 728 580
5.8 65 95 130 754 605
6.0 65 100 130 780 625
6.2 70 100 135 806 645
6.4 70 105 140 832 665
6.6 75 110 145 858 685
6.8 75 110 150 884 705
7.0 75 115 155 910 730
7.2 80 120 160 936 750
7.4 80 120 160 962 770
7.6 85 125 165 988 790
7.8 85 130 170 1014 810
8.0 90 130 175 1040 830
8.2 90 135 180 1066 855
8.4 90 140 185 1092 875
8.6 95 140 190 1118 895
8.8 95 145 195 1144 915
9.0 100 145 200 1170 935
9.2 100 150 200 1196 960
9.4 105 155 205 1222 980
9.6 105 155 210 1248 1000
9.8 110 160 215 1274 1020
10.0 110 160 220 1300 1040
*Volumes in these columns are rounded to the nearest 5 ml.
*Feed 2 - hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 waterly stools per
day), and finishing most feeds, change to 3-hourly feeds.
*After a day on 3-hourly feeds. "if no vomiting, less diarrhoea , and finishing most feeds, change to 4-hourly feeds.

33
 ANNEXURE 6.
Volume of F-75 for children with severe (+++) oedema
Weight of +++ Volume of F-75 per feed (ml) Daily total 80% of daily
oedema (kg) Every 2 hours Every 3 hours Every 4 hours (100 ml/kg) total
(12 feeds) (8 feeds) (6 feeds) (minimum)
3.0 25 40 50 300 240
3.2 25 40 55 320 255
3.4 30 45 60 340 270
3.6 30 45 60 360 290
3.8 35 50 65 380 305
4.0 35 50 65 400 320
4.2 35 55 70 420 335
4.4 40 55 75 440 350
4.6 40 60 75 460 370
4.8 40 60 80 480 385
5.0 45 65 85 500 400
5.2 45 65 85 520 415
5.4 45 70 90 540 430
5.6 50 70 95 560 450
5.8 50 75 95 580 465
6.0 50 75 100 600 480
6.2 55 80 105 620 495
6.4 55 80 105 640 510
6.6 55 85 110 660 530
6.8 55 85 115 680 545
7.0 60 90 115 700 560
7.2 60 90 120 720 575
7.4 60 95 125 740 590
7.6 65 95 125 760 610
7.8 65 100 130 780 625
8.0 65 100 135 800 640
8.2 70 105 135 820 655
8.4 70 105 140 840 670
8.6 70 110 145 860 690
8.8 75 110 145 880 705
9.0 75 115 150 900 720
9.2 75 115 155 920 735
9.4 80 120 155 940 750
9.6 80 120 160 960 770
9.8 80 125 165 980 785
10.0 85 125 165 1000 800
10.2 85 130 170 1020 815
10.4 85 130 175 1040 830
10.6 90 135 175 1060 850
10.8 90 135 180 1080 865
11.0 90 140 185 1100 880
11.2 95 140 185 1120 895
11.4 95 145 190 1140 910
11.6 95 145 195 1160 930

34
 11.8 100 150 195 1180 945
12.0 100 150 200 1200 960
*Volumes in these columns are rounded to the nearest 5 ml.
*Feed 2 - hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 waterly stools per
day),and finishing most feeds, change to 3-hourly feeds.
*After a day on 3-hourly feeds. "if no vomiting, less diarrhoea , and finishing most feeds, change to 4-hourly feeds.

ANNEXURE 7.
Catch -up (F-100)diet (Free Feeding )Reference Chart
Weight of Child Range of volumes pe 4 hourly feed of F-100 (6 Range of daily
(kg) feeds daily) Volume of F-100
Minimum
Minimum Maximum Maximum(220
(150
(ml) (ml) ml/kg/day
ml/kg/day)
2.0 50 75 300 440
2.2 55 80 330 484
2.4 60 90 360 528
2.6 65 95 390 572
2.8 70 105 420 616
3.0 75 110 450 660
3.2 80 115 480 704
3.4 85 125 510 748
3.6 90 130 540 792
3.8 95 140 570 830
4.0 100 145 600 880
4.2 105 155 630 924
4.4 110 160 660 968
4.6 115 170 690 1012
4.8 120 175 720 1056
5.0 125 185 750 1100
5.2 130 190 780 1144
5.4 135 200 810 1188
5.6 140 205 840 1232
5.8 145 215 870 1276
6.0 150 220 900 1320
6.2 155 230 930 1364
6.4 160 235 960 1408
6.6 165 240 990 1452
6.8 170 250 1020 1496
7.0 175 255 1050 1540
7.2 180 265 1080 1588
7.4 185 270 1110 1628
7.6 190 280 1140 1672
7.8 195 285 1170 1710
8.0 200 295 1200 1760
8.2 205 300 1230 1804
8.4 210 310 1260 1848
8.6 215 315 1290 1892
8.8 220 325 1320 1936
9.0 225 330 1350 1980
9.2 230 335 1380 2024
9.4 235 345 1410 2068

35
 9.6 240 350 1440 2112
9.8 245 360 1470 2156
10.0 250 365 1500 2200
 Volumes per feed are rounded to the nearest 5 ml.

ANNEXURE 8.
Antibiotic reference chart
STATUS ANTIBIOTICS

All admitted cases without any complications  Inj. Ampicillin 50 mg/kg/dose 6 hrly
or complication other than shock, meningitis and Inj. Gentamicin 7.5 mg/kg once a
or dysentery day for 7 days
 Add Inj.Cloxacillin 100 mg/kg day 6 hrly
if staphylococcal infection is suspected.
 Revise therapy based on sensitivity
report.
For septic shock or worsening /no  Give third generation cephalosporins
improvement in initial hours like Inj. Cefotaxime 150mg/kg/day in 3
divided doses or Ceftriaxone
100mg/kg/day in 2 divided doses along
with Inj Gentamicin 7.5 mg/kg single
dose.
(If Child is not passing urine,gentamicin
may accumulate in the body and cause
deafness Do not give second dose until
child is passing urine.

Meningitis  IV Cefotaxime 50mg/kg/dose 6hrly or

Inj Ceftriaxone 50 mg/kg 12 hrly plus
Inj.Amikacin 15mg/kg/day divided in
8hrly doses.
Dysentery  Give Ciprofloxacin 15mg/kg in two
divided doses per day for 3 days. If
child is sick or has already received
ciprofloxacin,give Inj.Ceftriaxone 100
mg/kg once a day or divided in 2 doses
for 5 days.

36
ANNEXURE 9.
Home made alternative food items

Example of Homemade culturally acceptable alternative to Catch-Up (F-100)diet.

1.Khichri
Ingredients Amount for 1 kg khichri
Rice 120 gms
Dal 60 gms
Edible Oil 70 ml
Potato 100 gms
Pumpkin 100 gms
Leafy Vegetable 80 gms
Onion (2 medium size) 50 gms
Spices (ginger, turmeric, coriander According to tasts
powder)
Water 1000 ml
Total Calories/kg 1,442 kcal
Total Protein/kg 29.6 gms

2.Halwa
Ingredients Amount for 1 kg
Wheat flour (atta) 200 gms
Lentils (dal)/Besan/Moong dal powder 100 gms
Oil (soya) 100 ml
Jaggery/Gur/Sugar 125 gms
Water to make a thick paste 600 ml
Total Calories /kg 2404 kcal
Total Calories/100 gm 240 kcal
Total Protein/kg 50.5gms
Total protein/100 gm 5.05gms

37
ANNEXURE 10.
Feeding recommendations as per IMNCI
GUIDELINES

Up to 6 months 6 to 12 months 12 months - 2 years 2 years and older

-Breast feed as -Breastfeed as often as -Breast feed as often as the Give family food
often as the child the child wants. child wants at 3 meals each
wants,day and day
night ,at least 8 -Give at least one katori -Offer food from the family
times in 24 serving* at a time. pot Also twice daily
give nutritious
Hours. -Mashed roti/ rice/ -Given at kast 1 1/2 katori food between
bread/biscuit mixed in serving at a time of meals such as
sweetened undiluted
Mashed roti/ rice/ bread/ banana/ biscuits
-Do not give any milk
other foods or OR mixed in thick dal with added mango/papaya as
fluids not even -Mashed roti/rice/ ghee oil or khichri with added snacks
oil ghee. Add cooked
water bread/ mixed in thick
dal with added ghee/ vegetables also in the servings
khichri with added ghee. OR
Add cooked vegetables Mashed roti/ rice/ bread/
also in the servings mixed in sweetended
OR undiluted
-Sevian / daliya/ OR
Sevian /daliya/ halva/kheer
halwa/kheer prepared
prepared in milk or any cereal
in milk or any cereal
package cooked in milk
porridge cooked in milk OR
OR Mashed boiled / fried
-Mashed boiled / fried potatoes Also give nutritious
potatoes Also given food between meals such as
nutritious food between banana/ biscuits /cheeko /
mango/papaya as snacks
meals such as banana/
biscuits /chooro /
mango/papaya as
snacks
Remember: Remember: Remember: Remember:
-Continue -Keep the child in your -Ensure that the child finishes -Ensure that the
Breastfeeding if lap and feed with your the serving child finishes the
the child is sick. own hands -Wash your child hands with serving
-Wash you own and soap and water every time -Teach your child
child hands with soap before feeding wash his hands
and water every time with soap and
before feeding water every time
before feeding

38
ANNEXURE 11.
Guidance to identify target weight

Weight on Target Weight: Weight on Admission Target Weight:

Admission 15 % Weight gain 15 % Weight gain
4.1 4.7 10.7 12.3
4.3 4.9 10.9 12.5
4.5 5.2 11.1 12.8
4.7 5.4 11.3 13.0
4.9 5.5 11.5 13.2
5.1 5.9 11.7 13.5
5.3 6.1 11.9 13.7
5.5 6.3 12.1 13.9
5.7 6.6 12.3 14.1
5.9 6.8 12.5 14.4
6.1 7.0 12.7 14.6
6.3 7.2 12.9 14.8
6.5 7.5 13.1 15.1
6.7 7.7 13.3 15.3
6.9 7.9 13.5 15.5
7.1 8.2 13.7 15.8
7.3 8.4 13.9 16.0
7.5 8.6 14.1 16.2
7.7 8.9 14.3 16.4
7.9 9.1 14.5 16.7
8.1 9.3 14.7 16.9
8.3 9.5 14.9 17.1
8.5 9.8 15.1 17.4
8.7 10.0 15.3 17.6
8.9 10.2 15.5 17.8
9.1 10.5 15.7 18.1
9.3 10.7 15.9 18.3
9.5 10.9 16.1 18.5
9.7 11.2 16.3 18.7
9.9 11.4 16.5 19.0
10.1 11.6 16.7 19.2
10.3 11.8 16.9 19.4
10.5 12.1 17.1 19.7

39
 MONTHLY REPORTING FORM: BAL SEWA KENDRA (CMTC)

Name of Health Facility:

Taluka: District:
Month: Year:
Number of beds:
Male Female Total
A. ADMISSIONS
SC /ST
BPL
Others
Total Admissions
A.1 Admission criteria
WFH <-3 SD
MUAC < 11.5 cm
SUW <-3 SD
Serious growth falter
Bilateral Pitting oedema
Loss of appetite
Infection (Specify)
1. Respiratory
2. GI tract
3. Septicaemia
4. Other
A.2 Referral By
OPD
Bal shaktim Kendra
AWC
MAMTA diwas
ANM
Private doctor/hospital
A.3 Duration of stay
< 7 Days
7 – 14 days
> 15 Days
A 4 Bed Occupancy
Bed Occupancy Rate
A 5 Weight gain
Achieved target weight (15% weight
gain)
Monthly Output
1. Discharges from Bal Sewa Kendra
2. Referred to NRC
3.
4.
5.
6.

40
 QUARTERLY REPORTING FORMAT OF BAL SEWA KENDRA FOR DISTRICT

District: Period :
Staff
Trained
in
Bal Sewa Kendra details
Human resources ( SAM+
at Bal Sewa FIMNCI Outputs ( Total numbers
kendra in place package) during the quarter)
Bed Occupancy rate in last
Date of operationalisation

Discharge with target

Cook cum Care taker
No. of Facility

Attendant (Cleaner)
where Bal

Referred back
Admissions

weight gain
Nutritionist
No. of beds

Defaulters
Referrals
sewa Kendra
quarter

Deaths
MO

MO
SN

SN
and is
located
(Name of the
center)
S.No.

41
 REFERRAL SLIP FROM BAL SEWA KENDRA TO BAL SANJEEVANI KENDRA

Name of the Bal Sewa kendra:

Name of the child:

Age of the child: Sex of the child :M /F

Date of Admission at Bal Sewa Kendra: Date of referral:

Child was admitted to Bal Sewa Kendra with:

SUW / SAM / Serious Growth falter/ Infection/ Bilateral oedema on legs/ Loss of appetite

Child is referred to Bal Sanjeevani Kendra (NRC) with:

No improvement/ Infection not responding/ Child’s condition worsening/ Child in need of tertiary level
care

Details of Treatment and Nutrition therapy:

Type of Nutrition therapy-----------------------------------Given for ---------days

Name of Antibiotics-------------------dosage-------------------Given for -----------

Micronutrient supplements given: (Mention no.of days of supplement in ( )

Vit. A/ IFA ( ) / zinc ( ) / other

Enclosures:

MAMTA card / Payment receipt

Signature of Doctor incharge

42
 REFERRAL SLIP FROM BAL SEWA KENDRA TO BAL SANJEEVANI KENDRA

Name of the Bal Sewa kendra:

Name of the child:

Age of the child: Sex of the child :M /F

Date of Admission at Bal Sewa Kendra:

Date of discharge for care and support at Bal Shaktim Kendra (VCNC):

Child was admitted to Bal Sewa Kendra with:

SUW / SAM / Serious Growth falter/ Infection/ Bilateral oedema on legs/ Loss of appetite

Status of Child when referred back to Bal Shaktim Kendra (VCNC):

Weight-------------, MUAC-----------, No infection/ Appetite normal/ No oedema

Details of Nutrition therapy:

Vit. A syrup: To be given/ Not to be given

IFA To be given as -------------------------------- for -----------Days

Zinc To be given as -------------------------------- for -----------Days

Any other suppl.--------------------------------- To be given as -------------------------------- for

-----------Days

Signature of Doctor incharge

(All discharged children should be taken care at Bal shaktim Kendra for
minimum 2 months after discharge/ till child enters green
classification)

43