OPERATIONAL GUIDELINES NUTRITION REHABILITATION CENTRE (NRC)

OPERATIONAL GUIDELINES NUTRITION REHABILITATION CENTRE (NRC) Nutrition Rehabilitation Centre (NRC) is a unit in a health facility where children with Severe Acute Malnutrition (SAM) are admitted & managed. Children are admitted as per the defined admission criteria & provided with medical & nutritional therapeutic care. Once discharged from the NRC, the child continues to be in the Nutritional Rehabilitation program till she/he attains the defined discharge criteria from the program. In addition to curative care, special focus is given on timely, adequate & appropriate feeding for children & on improving the skills of mothers & caregivers on complete age appropriate caring & feeding practices. In addition, efforts are made to build the capacity of mothers/caregivers through counselling & support to identify the nutrition & health problems in their child. Objectives: 1. To provide clinical management & reduce mortality among children with severe acute malnutrition, particularly among those with medical complications. 2. To promote physical & psychological growth of children with severe acute malnutrition (SAM). 3. To build the capacity of mothers & other care givers in appropriate feeding & caring practices for infants & young children. 4. To identify the social factors that contributed to the child slipping into severe acute malnutrition. Location & size: A 10 bedded NRC should have a covered area of about 1950 square feet; this will include a patient area, play & counselling area, nursing station, kitchen, storage space, two bathrooms & two toilets. The unit should be a distinct area within the health facility & should preferably (not necessarily) be in proximity to the paediatric ward / in patient facility: The NRC should have the following: Patient area to house the beds; in NRC adult beds are kept so that the mother can be with the child. Play & counselling area with toys; audiovisual equipment like TV, DVD player & IEC materials. Nursing station. Kitchen & food storage area attached to ward, or partitioned in the ward, with enough space for cooking, feeding and demonstration. Attached toilet & bathroom facility for mothers & children along with two separate hand washing areas. Open space along side NRC, which can be converted to a kitchen garden & play area for children. NRCs should have a cheerful, stimulating environment; it should be child friendly. Walls can be brightly painted & decorated. Ward should have sufficient space for all mothers/ caregivers staying with the children to sit together & be given cooking & feeding demonstrations. 1

The following civil work is required: Floor surfaces: Floor surfaces should be easily cleanable & should minimize the growth of micro organisms Walls: As with floors, the ease of cleaning & durability of wall surfaces must be considered. Water supply: Unit should have 24 hour uninterrupted running water supply. Power supply: Unit should have a 24 hour uninterrupted stabilised power supply. Lighting: Should be well lit Ventilation: Should be adequately ventilated, especially for the kitchen area Mosquito & fly screen: Windows should be covered with mosquitoes & fly covers Services: The services & care provided for the in-patient management of SAM children include: 24 hours care & monitoring of the child Treatment of medical complications Therapeutic feeding Providing sensory stimulation & emotional care Social assessment of the family to identify & address contributing factors Counselling on appropriate feeding, care & hygiene. Demonstration & practice by doing on the preparation of energy dense child foods using locally available, culturally acceptable & affordable food items Follow up of children discharged from the facility Admission Criteria: The criteria for admission for inpatient treatment in a NRC are as follows: Children 6-59 months Any of the following: MUAC < 115mm or 11.5 cm with or without any grade of oedema WFH < -3 SD with or without any grade of oedema Bilateral pitting oedema +/++ (children with oedema +++ always need inpatient care) Any of the following complications: WITH 1. Anorexia (Loss of appetite) 2. Fever (39 degree C) or Hypothermia (<35 C) 3. Persistent vomiting 4. Severe dehydration based on history and clinical examination 5. Not alert, very weak, apathetic, unconscious, convulsions 6. Hypoglycemia 7. Severe Anemia (severe palmar pallor) 8. Severe pneumonia 9. Extensive superficial infection requiring IM medications 10. Any other general sign that a clinician thinks requires admission for further assessment or care 2

Infants < 6 months Infant is too weak or feeble to suckle effectively (independently of his/her weight-for-length) or WfL (weight-for-length) < -3SD (in infants >45cm) or Visible severe wasting in infants <45cm or Presence of oedema both feet Children may be referred to NRC from Pushtikar Diwas / VHND / Paediatric ward etc. or may come directly to NRC but admission will be done only if the child meets the above mentioned criteria. Human Resources: The following staffs may be recruited for 10 bedded NRCs: Staff Position Sanctioned position Salary (Per month) Eligibility Criteria Remarks Medical Officer 1 @Rs.6, 000/- Paediatric Specialist of the facility is preferred or any other Specialist /MBBS Doctor trained in facility based care of SAM Part-time (From the system) Nutritionist- cum- Counsellor 1 @Rs.10,000/- Candidate must be a woman with Graduation in Home Science (Honours or Pass) Full-time ANM / Nursing Assistant 4 (Ratio:-1:3 i.e.1 ANM: 3 Nursing Asst.) @Rs. 5,200/- Candidate must have passed the HSC examination & must have undergone 1 1/2 years training for multipurpose health worker (female) at the approved government training centres / recognised private institutions & must have registered with the Orissa Nursing Council. OR In case of unavailability of ANMs, trained ANMs not registered under Nursing Council or passed from Private colleges may be recruited as Nursing Assistants @ Rs. 5,000/- per month. Maximum 3 Nursing Assistants may be recruited. In case of unavailability of ANMs, retired ANMs within 65 years of age as on closing date for receipt of application @Rs. 5,200/- per month may be considered. Cook- cumattendant 3 @Rs. 4,440/- 7 th Class pass, women candidates are required To be outsourced The Job Responsibilities of each NRC staff is enclosed in Annexure-i. 3

NOTE: i. Applicants working in the health department either on regular or on contractual basis should apply through proper channel. ii. Applicant should not have been disengaged from the Society on administrative grounds such as disobedience, poor performance, misbehaviour, criminal activity prior to applying for the posts. iii. Upper age limit for all the positions (except Medical Officer) is 65 years as on closing date of receipt of application. Equipment & supplies: The list of equipment & supplies required for the NRC is enclosed in Annexure-ii. Training: 3 days training on Facility Based Management of SAM to be provided to the Medical Officer, ANMs & the Nutrition Counsellor. Structured Play Therapy: Emotional & physical stimulation can substantially reduce the risk of permanent mental retardation & emotional impairment. Examples of outdoor games & simple toys may be seen in Annexure-iii. Follow-up of children discharged from NRC: Children discharged from the NRC should be followed up at the community level to ensure appropriate feeding, follow up at the NRC for scheduled visits & to identify children who are not responding to treatment for referral to the facility level. Discharge from the facility (NRC) Enrolment in AWC Supplementary nutrition Home visits by Anganwadi Worker/ASHA Inform nearest SC/PHC & concerned ANM Timely follow-up ASHA to accompany the child to NRC AWW & ANM to conduct follow-up assessment & monitoring of growth & development during VHNDs till child recovers completely Monitoring & Supervision: The trained Medical Officer shall supervise the staff of the NRC & provide hands on training & feedback based on the analysis of monthly data from NRC. The utilisation of services & quality of care being provided in the NRC shall be monitored on a regular basis, as per the following gender & age disaggregated indicators: Indicators Number of NRCs Admissions Gender disaggregated Referred by frontline worker/self/paediatric ward or emergency 4 Indicators to be monitored at NRC

Bed occupancy rate Average length of stay in the NRC Weight gain during stay in the NRC Rate of referral to higher facility Case fatality rate Defaulter rate Relapse rate Non-responders Death rate following discharge from NRC At the District level, the progress of the NRC is to be reviewed during the monthly convergence meeting of ICDS & Health, chaired by the District Collector. At the State level, the progress of the NRC is to be reviewed regularly in the Child Health Review meetings & Convergence meeting of W&CD & Health etc. Records & Registers: The following records & registers are to be maintained at the NRC: i. Monthly NRC Report ii. Child information sheet iii. Discharge Ticket & Follow up iv. Follow-up register v. Wage compensation register vi. Medicine Stock register vii. Contact Information register viii. Visitors register The following are to be displayed at the NRC: Counselling chart 24 hour food intake chart Daily ward feeding chart Photographs of all children at the time of admission & discharge from NRC need to be documented & displayed at the NRC. Sample of the records & registers to be maintained and charts to be displayed in the NRC is enclosed in Annexure-iv. Reporting: Monthly & Quarterly Report as per format enclosed in Annexure-v is to be submitted to the DFW & NRHM by the 10 th of every month in the following email id: orissastatemcscell@rediffmail.com sdo1nrhm@gmail.com NOTE: Monthly report is to be submitted by the districts from the month of July 2012 & Quarterly Report from 2 nd Quarter (July to September 2012). 5

Srl. No. Item Cost estimate / month Annual cost (in Rs) iii) Medicine, clinical 5,000/- 60,000/- 6 Budget Head A Non recurring cost 1 Civil work 10,00,000/- Budget under Civil Work 2 Equipments, instruments, furniture, computer (with internet connection) & printer, camera (digital), washing machine etc. B Recurring cost 1 Personnel cost: Medical Officer (Parttime): 1 no. @ Rs. 6000/- p.m. Nutritionist cum - Counsellor: 1 no. @ Rs. 10,000/- p.m. ANM / Nursing Asst.- 4 nos. (Ratio - 1:3) ANM @Rs. 5200/- / Nursing Asst. @ Rs. 5000/- p.m. Cook-cum-Attendant: 3 nos. @ Rs.4440/- p.m. 2,00,000/- Budget under Procurement 67,700/- 8,12,400/- Budget under Human Resource 2 Running cost : 95,000/- 11,40,000/- Budgeted under Child Health Cost estimation of NRC (Annex) i) Food/Diet: ii) Therapeutic Diet for Child: @Rs. 50/- per day Diet for Mother:@Rs. 60/- per day Compensation to Primary Care Givers Remarks As per estimate. Assistant Engineer, NRHM shall prepare the plan & estimate and also supervise the work. Technical sanction is to be accorded by APD (Tech) of respective districts. Work will be executed by ZSS through tender process. Includes day to day management -food, drugs, wage compensation, fuel, consumables, stationery (formats & registers) etc. 66,000/- 7,92,000/- Child has to be fed according to SAM management protocol. Mother/care giver staying with the child should be provided food from the health facility. 21,000/- 2,52,000/- Primary care givers will be given household chores /cash incentive for loss of wages amounting to maximum Rs. 700/- @Rs.50/- per day.

investigation & micro nutrients required, if any when same facilities are not available in hospital. iv) Event management 1,000/- 12,000/- Observation of related days, competition among inmates, recognition for involvement in the programme, birthday celebration of babies etc. v) Printing, Xeroxing, 500/- 6,000/- photographs etc. Documentation & reporting vi) Establishment cost 1,500/- 18,000/- Follow up Performance Incentive to ASHA (Total@Rs.150/- per child ) for: 1. Accompanying SAM cases to NRCs @Rs.50/- per case, on admission. 2. Remaining 100/- to be paid when: a) Case stays for minimum 7 days in NRC & ASHA accompanies the child to NRC for first 2 followups. b) Regular follow up after discharge for 6 months. c) On diagnosis when the case is found not to be in the SAM category. Training Budgeted under Incentive to ASHA under Child Health Budget under training Incentive to ASHAs for accompanying cases to NRC & follow up for 6 months. 7

ANNEXURES Annexure-i JOB DESCRIPTION: Medical Officer: MO will be the overall in-charge of the unit & will be responsible for clinical management of children admitted in the NRC. MO will examine each patient every day & will attend to emergency calls as per need. MO will ensure that screening has been done properly, prescribe treatment as per recommended Guidelines & monitor the progress of the child admitted in NRC. Nutrition Counsellor: Supervisor of the unit, trainer & Counsellor for the staffs posted in the NRC as well as mothers / caregivers. Chart out specific therapeutic diet plan for each child as per the Guidelines in consultation with the Medical Officer. Responsible for monitoring the preparation & distribution of feeds as per diet charts, maintaining NRC records in registers, preparing reports of the NRC & in diet & treatment sheets. Assess the feeding problem in each child & give individual counselling to mothers. Nutrition Counsellor will bring all mothers & caregivers of the admitted children together & give demonstration on making low cost nutritious energy dense culturally acceptable child foods Provide group counselling on various topics like nutrition & malnutrition, hygiene & sanitation, infant & young child feeding practices, immunisation, family planning etc. Provide counselling & demonstrate to mothers on structured play therapy for psychosocial stimulation to engage children in play therapy for at least 30 minutes play each day. Provide group counselling to mothers of all children admitted in the health facility (eg. Paediatric or general ward) and also to mothers of children presenting in outpatients department on designated days (eg. Immunisation day). Oversee the cleanliness & ensure hygiene practices at NRC. Ensure that the child is provided services as per the recommended Guidelines. Ensure that the NRC data is updated & entered in the NRC software. Responsible for reporting & analysis of NRC data & ensuring follow up of the children discharged from the NRC. Preparation of database for each block in the district i.e. database of the Anganwadi Centre, SC & PHC and name & contact number of the AWW/ANM & ASHA. Fill up the discharge cards with the support of the ANMs & counsel mothers/relatives regarding follow-up schedule at the NRC & home visits by AWW/ANM/ASHA. Nutrition Counsellor of the NRC trained on IYCF will be given additional responsibility to visit the Gynaecology ward, Paediatric ward & SNCU to interact with the mothers and provide them one- to -one counselling on IYCF, twice a week. Nurse: Responsible for nursing care including weight record; measure, mix & dispense feed. Give oral drugs. Supervise intra venous fluids. 8

Assess clinical signs & fill the multi chart with all the routine information. Counsel the mothers/caregivers on the emotional needs of her child & encourage them to give sensory stimulation. In charge of structured play therapy. Carry out screening as per the recommended Guidelines. Give medicine & treatment (injectables) as per the MOs Guidance & advice. Ensure that all steps in the management of SAM cases are followed in the NRC. Fill the daily intake sheet, the SAM information sheet & consult with Nutritionist on the feeding time table of all children at the NRC. Cook: Prepare therapeutic diet (F 75 & F 100) for children as prescribed by the Medical Officer under the supervision of the Nutrition Counsellor. Involve mothers & care givers of admitted children in preparation of food. Purchase food items locally under the supervision of the Nutrition Counsellor. Clean the utensils, kitchen & the equipment used in the kitchen for the preparation of food. Attendant: Responsible for managing the cleaning duties & the provision of detergents, hand soaps, chlorine etc. Floors should be cleaned every day with soap & water. Toilets should be disinfected with 0.5% active chlorine solution. 9

DETAILS OF EQUIPMENTS & SUPPLIES: Essential Ward Equipments: Glucometer-1 no. Thermometers (preferably low-reading)-2 nos. Weighing scales: (Digital of 1 gram fraction) (3 nos. : One each to be kept in ward, outpatient & emergency area) Infantometer (1 each for OPD & NRC) Stadiometer (to measure standing height) -1 no. Resuscitation equipments Suction equipments (low pressure) Pharmacy Supplies: ORS Electrolyte & minerals Potassium chloride Magnesium chloride/sulphate Iron syrup Multivitamin Folic acid Vitamin A Syrup Zinc Sulphate or dispersible zinc tablets Glucose (or sucrose) IV fluids (Ringer lactate solution with 5% glucose; 0.45% (half normal)saline with 5% glucose; 0.9% saline(for soaking eye pads) Kitchen Equipments Cooking gas Dietary scales (to weigh to 5 gms) Measuring jars Electric Blender (or manual whisks) Water filter Refrigerator Utensils (large containers, cooking utensils, feeding cups, saucers, spoons, jugs etc.) Other Ward Equipments: IV stands Almirah Shoe rack & dustbin Annexure-ii Room Heaters IEC-audio/visual materials (TV;DVD player) Toys for structural play (Safe, homemade toys can be used as well) Clock Calculator Reference height & weight charts Antibiotics: (Ampicillin/Amoxcillin/Benzyl penicillin) Chloamphenicol Cotrimoxazole Gentamycin Metronidazole Tetracycline or chloramphenicol eye drops Atropine eye drops Consummables: Cannulas IV Sets Paediatric nasogastric tubes Kitchen Supplies Supply for making starter & catch up diet Dried skimmed milk Whole dried milk Puffed rice Vegetable oil Foods similar to those used in home (for teaching /use in transition to home) 10

Annexure-iii OUTDOOR GAMES SUGGESTED FOR NUTRITION REHABILITATION CENTRE SPECIFICATIONS): (SUGGESTED Frog Slides: Features: The sliding portion is made of stainless steel sheet for maximum safety. In fact all our slides come with joint less stainless steel sheets Suitable for all age groups Specifications: This is a slide of size 1.2 m height. Rider Swing: Features: This swing comes with animal riders Specifications: Size of 3.0 m x 1.5 m Jungle Gym Climbers: Features: Multi utility climber suitable for various age groups Due to a compact size, it can fit in most play areas even those with space restrictions Provides for good exercise for leg & calf muscles Specifications: Sizes: 1.5m height Compact size of 1.2m x 1.2m footprint. Standard See Saw: Features: Highly reinforced & suitable for public spaces Specifications: This is a standard 4 seater see saw of size 1.5 m x 2.1m 11

Merry cone Round: Features: This is a merry go round for the tiny tots. Individual FRP seats with back rest is provided for comfort. Specifications: 1.5m (4 seater), & 2.1 m (6 seater) diameters Plastic sheets Bicycle: Frame & fork, Steel, MIG Welded Size- 12 /16 /20 Accessories like chain cover, carrier basket, back rest, wheel stabiliser, bell From reputed company with ISO certification Tricycle: Child tricycle with ISO 9001 certification & having safety standard certification. 12

EXAMPLES OF SIMPLE TOYS (ADAPTED FROM WHO GUIDELINES): Ring on a string (from 6 months): Rattle (from 12 months): Thread cotton reels & other small objects Cut long strips of plastic from coloured (e.g. cut from the neck of plastic bottles) on plastic bottles. Place them in a transparent to a string. Tie the string in a ring. Leaving a plastic bottle & glue the top on firmly. long piece of string hanging. Drum(from 12 months): Any tin with a tightly fitting lid. Mirror(from 18 months): A tin lid with no sharp edges. In and out toy (from 9 months): Any plastic or cardboard container & small objects (not small enough to be swallowed) Posting bottle (from 12 months): A large transparent plastic bottle with a small neck & small long objects that fit the neck (not small enough to be swallowed). Blocks (from 9 months): Small blocks of wood. Smooth the surfaces with sandpaper & paint in bright colours, if possible. Stacking bottle toys (from 12 months): Cut at least three identical round plastic bottles in half & stack them. Push along toys (from 12 months): Make a hole in the centre of the base & lid of a cylindrical shaped tin. Thread a piece of wire (about 60 cm long) through each hole & tie the ends inside the tin. Put some metal bottle tops inside the tin & close the lid. Pull along toys (from 12 months): As above, except that string is used instead of wire. Nesting toys (from 9 months): Cut off the bottom of two bottles of identical shape, but different size. The smaller bottle should be placed inside the large bottle. Doll (from 12 months): Cut out two doll shapes from a piece of cloth & sew the edges together, leaving a small opening. Turn the doll inside out & stuff with scraps of materials. Stitch up the opening & sew or draw a face on the doll. Book (from 18 months): Cut out three rectangular shaped piece of the same size from a cardboard box. Glue or draw a picture on both sides of each piece. Make two holes down one side of each piece and thread string through to make a book. Puzzle (from 18 months): Cut out three rectangular shaped piece of the same size from a cardboard box. Glue or draw a picture on both sides of each piece. Make two holes down one side of each piece & thread string through to make a book. 13

Monthly NRC Report: RECORDS & REGISTERS TO BE MAINTAINED AT THE NRC: Annexure-iv 14

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Child Information Sheet: 16

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Discharge ticket & follow-up card: 19

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Follow Up Register (TAKE TWO PAGES OF REGISTER): Srl. No. SAM Regd. No Name of Child Fathers Name Sex Age Address & Contact No Contact Person Details of The child Discharg e/ LAMA Follow Up 1 st 2 nd 3rd 4 th Advised Actual Advised Actual Advised Actual Advised Actual Advice 1 Date Ht or length Wt MUAC Z score 2 Date Ht or Length Wt MUAC Z score 21

Format of Wage Compensation Register: Srl. No. SAM reg. No. Name of the patient Name of attendant Date of admission Date of discharge No. of days Amount of Rs. 50/- to be given per day (@maximum Rs.700/- for the admitted child) Signature Medicine Stock Register: Sl. No Date Item Name Opening Balance Quantity Received Quantity Issued Total Quantity in Stock Signature 22

Contact Information Register: Sl. No. Block Name of CHC/PHC Name of SC Name of AWC Name & phone number of AWW ANM ASHA Visitors Register: Sl. No. Date Name Address & Phone No. Observations 23

Counselling Chart: DAYS Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 TOPICS Causes of malnutrition in children General hygiene & sanitation (personal & environmental) Immunization (ANC & children using MCP card) Nutritional care for young children Care of sick children Appropriate way of cooking food How to make nutritious food with available resources at home Breast feeding practices Complementary feeding practices Providing sensory stimulation & emotional support through play activities Care of mother & family planning Importance of weighing the child and growth monitoring Follow up & care at home after discharge from NRC Follow- up and recap of all the sessions Hour Food Intake Chart Complete one chart for every 24 hour period Name:...SAM ID number: Admission (wt in Kg): Today s wt(kg) Date:..Type of Feed:....Give: Feeds of ml Time a. Amount offered (ml) b. Amount left in cup (ml) c. Amount taken orally (a-b) d. Amount taken by NG, if needed (ml) e. Estimated amount vomited (ml) f. Watery diarrhoea ( if present, yes) Column totals c. d. e. Total yes Total volume taken over 24 hours = amount taken orally (c) + amount taken by NG (d) - total amount vomited (e)=...ml 24

Daily Ward Feeding Chart Date: NRC Name:... Name of Child Starter( F-75) diet Catch up(f-100) diet Number feeds Amount/ feed (ml) Total (ml) Number feeds Amount/ feed (ml) Total (ml) Starter (F - 75) diet (total ml) needed Catch-up (F - 100) diet (total ml) for 24 hrs needed for 24 hrs Amount needed for hours* Amount needed for hours* Amount to prepare (round up to Amount to prepare (round up to whole litre) whole litre) *Divide daily amount by the number of times food is prepared each day. For example, if feeds are prepared every 12 hours, divide daily amount by 2. 25

REPORTING FORMATS Annexure-v Monthly Reporting Format: Nutrition Rehabilitation Centre Name of Health Facility: Block: Number of beds: Month: District: Year: A. Admissions SC/ST BPL Total Admissions A.1 Admission Criteria -3 SD WFH MUAC<115 Bilateral Pitting Oedema A.2 Referred By Frontline worker Self Paediatric ward/emergency A.3 Duration of stay <7 days 7-15 days >15 days A.4 Bed Occupancy Bed Occupancy Rate A.5 Weight gain Achieved target weight (15% weight gain) B. Monthly Output 1.Discharges from NRC 2.Defaulters 3.Non responders 4.Deaths 5.Children due for follow up (in the month) 6.Children followed-up during the month 7.Deaths during follow-up period (after discharge from NRC) 8.Relapse Male Female Total 26

Quarterly Reporting Format For District & State: State/District: Period: Srl. No. Facility where NRC is located (PHC/CHC/DH/ Medical College) & Name NRC Details Human Resources Training Status Date of operationalisation No. of beds Bed occupancy rate in the last quarter Medical Officer Staff Nurse Nutrition Counsellor Cook Attendants/Caretak er Medical Officer Staff Nurse Admissions Outputs (Total numbers during the Quarter Discharges with Target weight gain Referrals Deaths Defaulters Children followed up Signature of the Medical Officer In-charge/State Programme Officer: 27