Children's Nutritional Rehabilitation Program in Beira, Mozambique: A Retrospective Study.

Malnutrition is still a major public health issue in sub-Saharan Africa and Mozambique. The main aim of this study was to evaluate the adherence to the nutritional rehabilitation program (NRP) and its impact on the growth of malnourished children in Beira, Mozambique. The secondary aim was to verify the prevalence of HIV infection in malnourished children at the time of admission to the NRP. A retrospective observational study in Beira Central Hospital and 10 health centers in Beira, Mozambique, was conducted. All children 0 to 5 years of age with acute malnutrition admitted to the outpatient services of the NRP from March 2016 until February 2017 were included in the study. A total of 1,231 children with the following characteristics have been enrolled: 58% female; 33% severely malnourished; and 16.5% HIV-positive. Of the 198 (21.7%) children who completed the program, 177 (89.4%) recovered from malnutrition and 21 (10.6%) did not. Ten (1.1%) were hospitalized and 706 (77.2%) dropped out of the program. Among children who completed the program, the median weight-for-length and weight-for-height z-scores at admission were ≥ -3 and < -2; at discharge, these median z-scores were ≥ -1 (P < 0.001). Children with HIV infection and who were male had a higher prevalence of severe acute malnutrition (P < 0.001). Weight gain was found to be significant after 23 days (P = 0.004) of consuming supplements (ready-to-use therapeutic food). A diagnosis of the degree of malnutrition was accurate at admission for 70.5%; at discharge, this diagnosis was accurate for 67.2%. The NRP seems to be successful if correctly followed, even if it is limited by adherence problems. However, its effectiveness requires further investigation.

Relation between changes in weight parameters and height parameters in prepubertal children: daily weight gain and BMIi changes in relation to linear growth during nutritional rehabilitation of underweight children.

BACKGROUND: Early detection of abnormal weight loss or gain in childhood may be important for preventive purposes. Variable growth response to nutrition rehabilitation have been reported in children with failure to thrive (FTT) who do not have any chronic disease or systematic illness due to different clinical and nutritional approach in their management. AIM OF THE STUDY: To analyze the association of different body mass index (BMI) and BMI- SDS, to linear growth (Ht-SDS) in different BMI categories of prepubertal children. In addition, we studied the effect of weight changes on linear growth in a randomly selected group of prepubertal underweight children who received nutritional rehabilitation (NR) for 9±2 months. SUBJECTS AND METHODS: 102 children, between 1 and 9 years, followed at the General Pediatric Clinic, between January 2017 to December 2017, because of abnormal weight gain (decreased or increased) which was not associated with any acute or chronic illness were included in the study. Anthropometric measurements included weigh, height, Ht-SDS, BMI, and BMI-SDS. Children BMI-SDS were categorized into 4 groups: Group 1: BMI-SDS <-2, group 2: BMI-SDS <-1 but >-2, group 3 BMI-SDS >-1 but <2, group 4 BMI-SDS >2. We also evaluated the effects of weight changes on linear growth in a randomly selected group of underweight children who received nutritional counselling and oral nutritional supplementation (n = 51) for 9±months. RESULTS: HT-SDS in children of groups 1 and 2 (underweight and at risk of underweight children) was significantly lower than Ht-SDS of groups 3 and 4 (normal and overweight children). Ht-SDS in children of group 4 was significantly higher than the Ht-SDS of children in group 3. A significant linear correlation was found between BMI-SDS and Ht-SDS in these prepubertal children. DISCUSSION: After nutritional rehabilitation for a year, 55% of underweight children increased their BMI-SDS and 43% increased their Ht-SDS. Children who had weight gain >7g/d, over the whole period of follow-up, (n =14) increased their BMI-SDS and Ht-SDS significantly after versus before NR. The BMI-SDS and Ht-SDS did not increase significantly in the group of children who had weight gain <7 g/day. 28 children out of 51 improved their BMI-SDS after nutritional rehabilitation (group A) and 23 did not have improvement in their BMI-SDS (Group B). Group A had higher weight gain per day versus group B. Height growth velocity was significantly higher in Group B (7.4±3.6 cm/yr) versus group A (5.7±2.8 cm/yr). Ht-SDS increased significantly in the group of patients who had lower Ht-SDS before NR. Children who had faster linear growth velocity, after nutritional rehabilitation, did not increase their BMI-SDS. Linear regression showed a significant correlation between BMI-SDS and Ht-SDS supporting the notion that proper nutrition and maintaining normal BMI-SDS is essential for adequate gain in height. CONCLUSION: It appears that calculating the weight gain per day, BMI-SDS and Ht-SDS are clinically useful parameters to detect the effect of weight gain on linear growth and to monitor the nutritional management. Daily weight gain was correlated significantly to height growth rate during nutritional rehabilitation. Based on our findings and literature reports, we suggest an algorithm for follow-up of underweight/ malnourished children based mainly on anthropometric assessment.

Nutritional Status of Children with Cerebral Palsy-Findings from Prospective Hospital-Based Surveillance in Vietnam Indicate a Need for Action.

BACKGROUND: Lack of evidence on the burden and risk factors for malnutrition among children with cerebral palsy (CP) in Vietnam limits evidence-based interventions. We aimed to define the nutritional status of children with CP in Vietnam. MATERIALS AND METHODS: The study utilized data from active prospective hospital-based surveillance modelled on the Pediatric Active Enhanced Disease Surveillance system. Children (0-18 years) with CP attending the National Children's Hospital Hanoi, Vietnam between June-November 2017 were included. Data on demographic, clinical and rehabilitation status were collected following detailed neurodevelopmental assessment. Anthropometric measurements were taken. Nutritional status was determined using the World Health Organization guideline. RESULTS: Of 765 children (the mean (SD) age was 2.6 (2.5) years; 35.8% were female), 28.9% (n = 213) were underweight and 29.0% (n = 214) stunted. The odds of underweight were significantly higher among children aged >5 years and/or having a monthly family income of <50 USD. Underweight and/or stunting was high among children with quadriplegia (81%, n = 60 and 84.5%, n = 87) and/or Gross Motor Functional Classification System (GMFCS) level IV-V (62.5%, n = 45 and 67.0%, n = 67). Nearly one-third of intellectually impaired and more than half of hearing-impaired children were underweight and/or stunted. CONCLUSIONS: Poor economic status and increased motor severity increased vulnerability to malnutrition. Our findings will inform nutritional rehabilitation programs among these vulnerable children.

Population pharmacokinetics of abacavir and lamivudine in severely malnourished human immunodeficiency virus-infected children in relation to treatment outcomes.

AIMS: Describe the pharmacokinetics (PK) of the antiretroviral drugs abacavir and lamivudine in malnourished paediatric patients and relate to viral load outcomes after 12 and 48 weeks of treatment. METHODS: Severely malnourished human immunodeficiency virus-infected children were randomized to early (within 14 days) or delayed (after nutritional recovery) initiation of antiretroviral treatment (ART) using World Health Organization weight-band dosages. Abacavir and lamivudine concentrations were measured as a secondary objective on day 1 and day 14 and patients were followed-up to week 48. Population PK of abacavir and lamivudine were described using NONMEM. RESULTS: In total, 623 abacavir and 627 lamivudine concentrations were collected from 75 paediatric patients aged 0.1-10.8 (median 1.4) years. Abacavir PK was described by a 2-compartment model, patients randomized to early ART showed increased bioavailability of 31%. Apparent clearance (CL/F, L/h/7 kg) of abacavir increased from day 1 to day 14 from 3.33 (95% confidence interval 2.71-4.12) to 5.86 (95% confidence interval 4.78-7.3). A 1-compartment model described lamivudine PK, variability on CL/F was explained by maturation with age, with age at half-matured CL/F being 4 months. For both drugs allometrically scaled total body weight was related to CL/F and apparent volume of distribution. PK exposure did not correlate with virological outcomes or death at 12 or 48 weeks. CONCLUSION: Increases in Abacavir's CL/F between day 1 to day 14, bioavailability and PK variability with early start of ART was found in this cohort of severely malnourished children; however, these changes did not influence virological outcomes. The study supports the use of weight-band dosage tables.

How healthy are children one year after discharge from nutritional rehabilitation centres?

Nutritional rehabilitation centres (NRCs) have been established to ensure the nutritional recovery of severely malnourished children. The long-term nutritional outcomes in children discharged from NRCs have not been described. In this retrospective cohort study, the nutritional status of 514 children was assessed one year after discharge. Household and maternal data, as well as data regarding variables related to the children's stay at the NRC, were collected. A total of 33.4% had moderate malnutrition and 11.7% had severe malnutrition. The mean weight for height Z-score at admission, discharge and one year after discharge were -3.61, -1.90 and -2.34, respectively. Thus, long-term monitoring and follow-up of children discharged from NRCs till they achieve normal nutritional status is mandatory.

Use of tuberculin skin test for assessment of immune recovery among previously malnourished children in Ethiopia.

OBJECTIVE: To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls). RESULTS: At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved.

Recovery rate and associated factors of children age 6 to 59 months admitted with severe acute malnutrition at inpatient unit of Bahir Dar Felege Hiwot Referral hospital therapeutic feeding unite, northwest Ethiopia.

BACKGROUND: Despite numerous advances made in improving child health and the clinical management protocols for treating severe acute malnutrition at treatment centers, evidences concerning the treatment outcomes are scarce. Therefore, this study was conducted to assess the recovery rate and associated factors of severely acute malnourished children of age 6 to 59 months admitted to inpatient therapeutic feeding unit at Felege Hiwot Referral Hospital. METHODS: We conducted a hospital-based cross-sectional study including 401 severely malnourished children who were admitted from September 2012 to January 2016. Bivariable and a Multivariable logistic regression model were fitted to identify factors associated with recovery rate. Adjusted Odds ratio with its 95% CI was reported and P-value less than 0.05 was considered as significant. RESULTS: Fifty eight percent (58.4%) (95%CI: 53.1-64.1) of admitted children were recovered with a mean recovery time of 18 (±6.3) days. Being female, children who were fully and partially vaccinated, who had better MUAC measurement, who stayed longer in the hospital, and children who took routine vitamin-A supplementation had better recovery rate. However, children who had co-morbidity at admission, had human immune virus (HIV) and Tuberculosis (TB) infection, and who had edema were less likely to recover. INTERPRETATION: Recovery rate was low as compared to international SPHERE cutoff points (> 75% recovery rate). Interventions that could address the outlined factors would be helpful to improve treatment recovery rate of admitted children.

Colaboración multidisciplinaria en el tratamiento de un niño de 5 años de edad con desnutrición / Multidisciplinary colaboration in the treatment of a 5 year old boy with malnutrition

Objetivo: El presente artículo describe el tratamiento multidisciplinario de un niño de 5 años de edad con desnutrición, alimentación selectiva, inapetencia e hiperrespuesta a los estí- mulos orales y táctiles. Se utilizó una intervención basada en una estrecha colaboración entre un pediatra, una dietetistanutricionista y una terapeuta ocupacional para afrontar el problema de alimentación. Se presenta una descripción de los 4 meses y medio de tratamiento y 2 meses de seguimiento. Método: Se analizaron las entrevistas con la familia y las notas de evolución en pediatría, nutrición y terapia ocupacional. Se presenta la progresión hacia los objetivos nutricionales, de aceptación de alimentos y de participación activa en el proceso de alimentación. Resultados: La normalización del estado nutricional se documenta mediante el seguimiento del índice de masa corporal y de datos antropométricos por parte del pediatra y de la nutricionista. La mejora en la participación en las comidas y en la aceptación de una mayor cantidad y variedad de alimentos se documenta mediante entrevistas con los padres y observaciones directas en las sesiones de terapia ocupacional. La mejora en las respuestas al estímulo oral y táctil se documenta mediante un cuestionario estandarizado (Sensory Profile). Conclusión: Este caso clínico contribuye a la evidencia existente sobre la utilización de un enfoque multidisciplinario en los casos de niños con desnutrición y rechazo a la alimentación. La consideración de problemas sensoriales como factor subyacente al problema de alimentación ha sido clave en la mejoría nutricional de este niño. Asimismo, este caso clínico contribuye a la evidencia sobre el uso de la terapia ocupacional basada en el enfoque de la integración sensorial de la Dra. Ayres para abordar la relación entre el procesamiento sensorial, la conducta y el desempeño ocupacional (AU)

Objective: This article describes the multidisciplinary treatment of a 5 year old child with malnutrition, selective feeding, lack of appetite and sensory over-responsiveness to oral and tactile stimuli. An intervention based on a close collaboration between a pediatrician, a dietician-nutritionist and an occupational therapist was used to treat the feeding problem. A description of the 4 and half months of treatment and a 2 month follow-up is presented. Methods: Interviews with the family and pediatric, nutrition and occupational therapy progress notes are analyzed. Progress towards nutritional objectives, acceptance of food and active participation in the feeding process is presented. Results: The normalization of the nutritional status is documented through monitoring of body mass and anthropometric data by the pediatrician and nutritionist. Improvement in meal participation and acceptance of a greater amount and variety of foods is documented through interviews with parents and direct observations in the occupational therapy sessions. The improvement in oral and tactile sensory reactivity is documented using a standardized questionnaire (Sensory Profile). Conclusion: This clinical case report contributes to the existing evidence on the use of a multidisciplinary approach in the treatment of children with malnutrition and refusal to feed. Consideration of sensory issues as an underlying factor to the feeding problem has been instrumental in the nutritional improvement of this child. This clinical case also contributes to the evidence on the use of occupational therapy based on Dr. Ayres sensory integration approach in addressing the relationship between (AU)

Programmatic response to malnutrition in India, room for more than one elephant.

Programming platforms need to recognize the diversity of malnutrition epidemiology in India and choose appropriate implementation designs. With severe chronic malnutrition as the dominant epidemiologic entity, the net needs to be cast wide, focusing on food security, health care, agriculture, water and sanitation, livelihoods and womens empowerment. Community-based malnutrition treatment and prevention programs need to collaborate to complement treatment with socioeconomic and preventive interventions. Expansion of nutrition rehabilitation centers should be limited to areas/districts with high wasting. Pediatric services with nested nutrition services (including counseling) requires urgent strengthening. Continuum of Care is a weak link and requires strengthening to make both hospital and community-based models meaningful.

Zinc y desnutrición / Zinc and undernutrition

Son cuatro los nutrientes en que su deficiencia es importante en niños: hierro, yodo, vitamina A y zinc. Más o menos se calcula que hay 2 billones de personas en el mundo con algún grado de déficit de zinc. Los pacientes que están en riesgo de presentar deficiencias de zinc son los recién nacidos con bajo peso al nacimiento, bien sea prematuros, desnutridos in útero o hijos de madres desnutridas, en los cuales sus depósitos están reducidos. A diferencia de otros oligoelementos o micronutrientes, determinar el estado de déficit no es fácil. Los niveles séricos de zinc, están influenciados por factores no dietarios como infección, estrés o actividad física extenuante; al igual que por el ciclo circadiano.

Four nutrient deficiency that is important in children, iron, iodine, vitamin A and zinc. More or less it is estimated that 2 billion people in the world with some degree of zinc deficiency. Patients who are at risk for zinc deficiency are infants with low birth weight, either premature or malnourished in utero, undernourished mothers, in which their deposits are reduced. Unlike other trace elements or micronutrients, determine the deficit is not easy. Serum levels of zinc are not influenced by dietary factors such as infection, stress or strenuous physical activity, as well as by the circadian cycle.

Home visits by neighborhood Mentor Mothers provide timely recovery from childhood malnutrition in South Africa: results from a randomized controlled trial.

BACKGROUND: Child and infant malnourishment is a significant and growing problem in the developing world. Malnourished children are at high risk for negative health outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve childhood nourishment. The objective of this study is to evaluate whether the Philani program can rehabilitate malnourished children in a timely manner. METHODS: Mentor Mothers were trained to conduct home visits. Mentor Mothers went from house to house in assigned neighborhoods, weighed children age 5 and younger, and recruited mother-child dyads where there was an underweight child. Participating dyads were assigned in a 2:1 random sequence to the Philani intervention condition (n = 536) or a control condition (n = 252). Mentor Mothers visited dyads in the intervention condition for one year, supporting mothers' problem-solving around nutrition. All children were weighed by Mentor Mothers at baseline and three, six, nine and twelve month follow-ups. RESULTS: By three months, children in the intervention condition were five times more likely to rehabilitate (reach a healthy weight for their ages) than children in the control condition. Throughout the course of the study, 43% (n = 233 of 536) of children in the intervention condition were rehabilitated while 31% (n = 78 of 252) of children in the control condition were rehabilitated. CONCLUSIONS: Paraprofessional Mentor Mothers are an effective strategy for delivering home visiting programs by providing the knowledge and support necessary to change the behavior of families at risk.

Participation in a parent education programme in the Dominican Republic: utilization and barriers.

There has been a limited assessment of the extent of participation in parent education programmes and the factors influencing attendance. This is particularly the case for low- and middle-income countries. Experiences with an eight-session education programme offered to caregivers of malnourished children in the Dominican Republic were examined. Overall, 57% of a total of 143 caregivers completed more than half of the programme. This value increased from 41% to 79% following a midstream change in service delivery, which entailed concentrating the programme into a shorter period of time and pairing it with a more intensive child nutrition component. Other hypothesized variables did not predict attendance. Key barriers to attendance identified in qualitative interviews included lack of money for transportation, lack of an acceptable babysitter for other children and competing demands on the caregivers' time. Efforts to eliminate caregiver identified barriers may improve participation levels.

Dietary counseling in the management of moderate malnourishment in children.

BACKGROUND: Dietary counseling is an integral part of treating malnutrition. A first step toward improving the management of moderate malnutrition is to evaluate dietary messages in current programs and assess their adequacy and effectiveness. OBJECTIVES: To ascertain current recommendations regarding family foods for the treatment of moderate malnutrition and assess whether these are likely to meet nutritional requirements for rehabilitation; to review the effectiveness of dietary counseling in the management of moderate malnutrition. METHODS: Information was requested from 10 United Nations agencies or donors, 20 international nongovernmental organizations, 3 pediatric associations, and 6 national programs about the dietary advice they give to caregivers of moderately malnourished children. Adequacy was assessed by comparing dietary recommendations with nutritional requirements. Linear programming was used to identify problem nutrients. A literature search was conducted of studies using family foods for rehabilitating malnourished children. RESULTS: There was a greater emphasis on providing food supplements for rehabilitation than on utilizing family foods. Dietary recommendations were mostly vague and unlikely to be effective. Those developed by the World Health Organization and the Food and Agriculture Organization for well-nourished children may meet nutritional requirements in moderate malnutrition if the recommendations are made more prescriptive. Zinc and vitamin E emerged as possible problem nutrients. Intervention studies in wasted children suggest that counseling caregivers about family foods can achieve good rates of weight gain. CONCLUSIONS: Dietary counseling can be effective in managing malnutrition, but it is often weak or absent and should be strengthened. More attention will need to be given to formulating the messages and improving counseling skills.

Nutritional recovery in HIV-infected and HIV-uninfected children with severe acute malnutrition.

OBJECTIVE: Few studies have reported on nutritional recovery, survival and growth among severely malnourished children with HIV. This study explores nutritional recovery in HIV-infected and HIV-uninfected children during inpatient nutrition rehabilitation and 4 months of follow-up. DESIGN: Prospective cohort study. SETTING: Lilongwe district, Malawi. MAIN OUTCOME MEASURES: Weight gain, anthropometrics. RESULTS: In our sample of 454 children with severe acute malnutrition (SAM), 17.4% (n = 79) of children were HIV infected. None of the children were on antiretroviral therapy upon admission. Among the HIV-infected children, 35.4% (28/79) died, compared with 10.4% (39/375) in HIV-uninfected children (p<0.001). All children who survived achieved nutritional recovery (>85% weight for height and no oedema), regardless of HIV status. HIV-infected children had similar weight gain to HIV-uninfected children (8.9 vs 8.0 g/kg/d, not significant (NS)). Mean increases in z-scores for both subscapular (2.72 vs 2.69, NS) and triceps (1.26 vs 1.48, NS) skinfolds were similar between HIV-infected and HIV-uninfected children, respectively, during nutrition rehabilitation. 362 children were followed for 4 months, at which time mean weight for height z-score was similar in HIV-infected and HIV-uninfected children (-0.85 vs -0.64, NS). CONCLUSIONS: HIV-infected children with SAM have higher mortality rates than HIV-uninfected children. Among those who survive, however, nutritional recovery is similar in HIV-infected and HIV-uninfected children.

[Infant-juvenile malnutrition in Fo-Boure (Benin): Anthropometric data and management of malnourished children]. / Malnutrition infantojuvénile à Fo-Bouré (Bénin): données anthropométriques et prise en charge des enfants malnutris.

UNLABELLED: Acute malnutrition or emaciation in childhood is defined by a low ratio weight/height. In Benin, 8% of the children are concerned. In the north of Benin, the situation is alarming. The aim of this survey is to specify: (1) the characteristics of infantile malnutrition in rural area in the north of Benin and (2) the management of the malnourished children. SUBJECTS AND METHODS: A descriptive survey was conducted in a paediatric dispensary. Anthropometric data of children from 0 to 60 months were collected. The children with severe malnutrition were admitted to a nutritional rehabilitation centre. The methods were those recommended by the World Health Organization and were adapted to the local resources. RESULTS: The anthropometric data of 239 children were analyzed. The prevalence of emaciation was 33%. Thirty-eight children were admitted to the centre. Twenty-nine of the children recovered. DISCUSSION: This survey confirms the precarious situation in the north of Benin, which may be explained by socio-economic and climatic factors. It can be prevented partly by better food availability, but also by an education on mothers. The strategies must be updated according to their effectiveness in terms of public health and their local acceptability. CONCLUSION: The prevalence of malnutrition in Fo-Bouré is beyond the value used by WHO to define the zones where the nutritional situation requires nutritional rehabilitation centres.

[Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso]. / Prise en charge de la malnutrition aiguë sévère dans un centre de réhabilitation et d'éducation nutritionnelle urbain au Burkina Faso.

BACKGROUND: Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS: Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS: From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION: The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.